Provider Demographics
NPI:1689641110
Name:CORPUS, LORENZO MIL (MD)
Entity Type:Individual
Prefix:DR
First Name:LORENZO
Middle Name:MIL
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:8093 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-6646
Practice Address - Country:US
Practice Address - Phone:904-337-2050
Practice Address - Fax:904-337-2051
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3757064-00Medicaid
GA000616679AMedicaid
FLF87809Medicare UPIN
GA000616679AMedicaid
FL080072573Medicare PIN