Provider Demographics
NPI:1902098007
Name:CORBRIDGE, KELLY JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JOHN
Last Name:CORBRIDGE
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 1:2187 AIRWAY AVE.
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3669
Mailing Address - Country:US
Mailing Address - Phone:928-757-5005
Mailing Address - Fax:
Practice Address - Street 1:2187 AIRWAY AVE.
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3669
Practice Address - Country:US
Practice Address - Phone:928-757-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU37152Medicare UPIN
AZOD829Medicare PIN