Provider Demographics
NPI:1336213123
Name:CORPUZ, RAYMUNDO OBILLO JR (MD)
Entity Type:Individual
Prefix:
First Name:RAYMUNDO
Middle Name:OBILLO
Last Name:CORPUZ
Suffix:JR
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 1:21 PEPPERMILL RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3105
Mailing Address - Country:US
Mailing Address - Phone:718-774-0400
Mailing Address - Fax:718-774-8928
Practice Address - Street 1:666 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-3306
Practice Address - Country:US
Practice Address - Phone:718-774-0400
Practice Address - Fax:718-774-8928
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141614208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00471710Medicaid
NY00471710Medicaid