Provider Demographics
NPI:1417995432
Name:CORPUS, ROBERTO A JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
Last Name:CORPUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RJ
Other - Middle Name:
Other - Last Name:CORPUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3865 W FRONT ST STE 4AND5
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8101
Mailing Address - Country:US
Mailing Address - Phone:231-252-0414
Mailing Address - Fax:231-252-0416
Practice Address - Street 1:3865 W FRONT ST STE 4AND5
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8101
Practice Address - Country:US
Practice Address - Phone:231-252-0414
Practice Address - Fax:231-252-0416
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073600207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060B86046OtherGROUP BLUE SHIELD NUMBER
MI4610699Medicaid
MI0B86046Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
H69498Medicare UPIN
MI4610699Medicaid