Provider Demographics
NPI:1689896631
Name:CORPUS, KATHALINA (MD)
Entity Type:Individual
Prefix:
First Name:KATHALINA
Middle Name:
Last Name:CORPUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420
Mailing Address - Country:US
Mailing Address - Phone:270-685-3162
Mailing Address - Fax:
Practice Address - Street 1:1228 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2716
Practice Address - Country:US
Practice Address - Phone:270-685-3162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431501207Q00000X
KY44364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000727680OtherANTHEM PIN
KY7100177980Medicaid
KY000000727680OtherANTHEM PIN