Healthcare Provider Details

I. General information

NPI: 1528078011
Provider Name (Legal Business Name): COLLEEN CORBETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 PARK PL
APPLETON WI
54914-8872
US

IV. Provider business mailing address

21 PARK PL
APPLETON WI
54914-8872
US

V. Phone/Fax

Practice location:
  • Phone: 920-739-4361
  • Fax: 920-739-6368
Mailing address:
  • Phone: 920-739-4361
  • Fax: 920-739-6368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberWI27950
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: