Provider Demographics
NPI:1801998968
Name:WARNER, COREY (MD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WARNER
Suffix:
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 1:18990 COYOTE VALLEY RD STE 10
Mailing Address - Street 2:
Mailing Address - City:HIDDEN VALLEY LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95467-8339
Mailing Address - Country:US
Mailing Address - Phone:707-987-8344
Mailing Address - Fax:
Practice Address - Street 1:18990 COYOTE VALLEY RD STE 10
Practice Address - Street 2:
Practice Address - City:HIDDEN VALLEY LAKE
Practice Address - State:CA
Practice Address - Zip Code:95467-8339
Practice Address - Country:US
Practice Address - Phone:707-987-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103245207R00000X
CAC53422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH24310Medicare UPIN