Provider Demographics
NPI:1043297666
Name:CORBEN, MICHAEL A (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:CORBEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23206 LYONS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2667
Mailing Address - Country:US
Mailing Address - Phone:661-259-2168
Mailing Address - Fax:
Practice Address - Street 1:23206 LYONS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2667
Practice Address - Country:US
Practice Address - Phone:661-259-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4954T152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT69974Medicare UPIN
CAOP4954Medicare PIN