Provider Demographics
NPI:1275647455
Name:CORBETT, CRISTA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CRISTA
Middle Name:MARIE
Last Name:CORBETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST STE 2400
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-6072
Mailing Address - Fax:916-734-6197
Practice Address - Street 1:4860 Y ST STE 2400
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-6072
Practice Address - Fax:916-734-6197
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2296152W00000X
AZ1426152W00000X
CA11545 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ741224Medicaid
AZAZ0905460OtherBCBS
AZ030078Medicare Oscar/Certification
AZU87962Medicare UPIN
AZ741224Medicaid