Provider Demographics
NPI:1952668220
Name:LUM, COREY JONATHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:JONATHAN
Last Name:LUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:
Practice Address - Street 1:10105 BANBURRY CROSS DR STE 460
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6645
Practice Address - Country:US
Practice Address - Phone:702-360-7600
Practice Address - Fax:702-363-3814
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1665207RA0001X, 207RC0000X
NVDO3065207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI819493Medicaid
NVDO03065OtherSTATE LICENSE