Provider Demographics
NPI:1679679849
Name:CORPUS, ROBERTO P (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:P
Last Name:CORPUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1644
Practice Address - Country:US
Practice Address - Phone:270-825-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17830207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000044237OtherBCBS PROVIDER NUMBER
KY64178304Medicaid
KY17830OtherLICENSE
KY64178304Medicaid
KY00503045Medicare PIN
000000044237OtherBCBS PROVIDER NUMBER
C64359Medicare UPIN
KY0536401Medicare PIN
KY220025678Medicare PIN