Provider Demographics
NPI:1265534986
Name:REPETTO, CORINNA (MD)
Entity type:Individual
Prefix:DR
First Name:CORINNA
Middle Name:
Last Name:REPETTO
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 1:1155 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-5016
Mailing Address - Country:US
Mailing Address - Phone:812-336-1690
Mailing Address - Fax:812-349-1311
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2317
Practice Address - Country:US
Practice Address - Phone:812-353-6821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037634A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200163730Medicaid
IN01037634AOtherIN LICENSE
01037634BOtherCSR
BR1901316OtherDEA
BR1901316OtherDEA
IN200163730Medicaid