Provider Demographics
NPI:1700920311
Name:AMBURGEY, CORBETT WALTER (OD)
Entity Type:Individual
Prefix:
First Name:CORBETT
Middle Name:WALTER
Last Name:AMBURGEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 E HALLETT ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-2080
Mailing Address - Country:US
Mailing Address - Phone:517-439-4136
Mailing Address - Fax:
Practice Address - Street 1:5575 BECKLEY RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4162
Practice Address - Country:US
Practice Address - Phone:269-979-1277
Practice Address - Fax:269-979-8040
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A311420OtherBLUE CROSS BLUE SHIELD
MI900A311420OtherBLUE CROSS BLUE SHIELD