Provider Demographics
NPI:1265970768
Name:CORUM, BRENT HOWARD (DPT)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:HOWARD
Last Name:CORUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2401 TOWNCREST DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-6631
Mailing Address - Country:US
Mailing Address - Phone:319-354-2429
Mailing Address - Fax:319-338-5775
Practice Address - Street 1:540 E JEFFERSON ST STE 302
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2460
Practice Address - Country:US
Practice Address - Phone:319-339-3611
Practice Address - Fax:319-339-3878
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06-65463Medicaid