Basic Information
Provider Information | |||||||||
NPI: | 1669474151 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORDERO | ||||||||
FirstName: | JUAN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3900 S ZINTEL WAY | ||||||||
Address2: |   | ||||||||
City: | KENNEWICK | ||||||||
State: | WA | ||||||||
PostalCode: | 993375092 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423627 | ||||||||
FaxNumber: | 5099422268 | ||||||||
Practice Location | |||||||||
Address1: | 1100 GOETHALS DR | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 993523304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423095 | ||||||||
FaxNumber: | 5099423097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2005 | ||||||||
LastUpdateDate: | 05/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | MD00047531 | WA | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 0237446 | 01 | WA | LABOR & INDUSTRIES | OTHER | 02597148 | 05 | NY |   | MEDICAID | 8478687 | 05 | WA |   | MEDICAID |