Healthcare Provider Details

I. General information

NPI: 1245687979
Provider Name (Legal Business Name): CORNELIO P. KATUBIG CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E JENKINS CT
HERNANDO FL
34442-8365
US

IV. Provider business mailing address

455 E JENKINS CT
HERNANDO FL
34442-8365
US

V. Phone/Fax

Practice location:
  • Phone: 352-527-3651
  • Fax:
Mailing address:
  • Phone: 352-527-3651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number036045548
License Number StateIL

VIII. Authorized Official

Name: DR. CORNELIO P KATUBIG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 352-527-3651