Provider Demographics
NPI:1134136229
Name:BUBP, CORBY ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CORBY
Middle Name:ALAN
Last Name:BUBP
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10291 N MERIDIAN ST
Mailing Address - Street 2:STE 310
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1083
Mailing Address - Country:US
Mailing Address - Phone:317-581-2288
Mailing Address - Fax:317-581-2295
Practice Address - Street 1:10293 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1123
Practice Address - Country:US
Practice Address - Phone:317-581-2288
Practice Address - Fax:317-581-2295
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042024103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200504340Medicaid