Basic Information
Provider Information | |||||||||
NPI: | 1710396486 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORREA | ||||||||
FirstName: | AMIT | ||||||||
MiddleName: | KEITH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1000, DEPT 457 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012753662 | ||||||||
FaxNumber: | 9012710155 | ||||||||
Practice Location | |||||||||
Address1: | 6410 FANNIN ST | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770303000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9015160792 | ||||||||
FaxNumber: | 9012666415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2014 | ||||||||
LastUpdateDate: | 10/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 55668 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | S3144 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.