Provider Demographics
NPI:1619039526
Name:CORBETT, CHARLES M (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:CORBETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4930 GRAHAM LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654
Mailing Address - Country:US
Mailing Address - Phone:662-893-6632
Mailing Address - Fax:
Practice Address - Street 1:4137 KIRBY PARKWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115
Practice Address - Country:US
Practice Address - Phone:901-794-3397
Practice Address - Fax:901-794-3398
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD038044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C72128Medicare UPIN