Provider Demographics
NPI:1902874480
Name:TABBERT, COREY H (OD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:H
Last Name:TABBERT
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 1:222 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1567
Mailing Address - Country:US
Mailing Address - Phone:218-631-2020
Mailing Address - Fax:218-631-1892
Practice Address - Street 1:222 SE FIRST STREET
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482
Practice Address - Country:US
Practice Address - Phone:218-631-2020
Practice Address - Fax:218-631-1892
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2883152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN365T9TAOtherBLUE PLUS
MNHP36359OtherHEALTHPARTNERS
MN1032301OtherPREFERREDONE
MN365T9TAOtherSOUTH COUNTY HEALTH ALLIANCE
MN22-02149OtherMEDICA
MN365T9TAOtherBLUECROSSBLUESHIELD
MN410002031Medicaid
MN999995765OtherVSP
MNMN2883OtherEYEMED
MN365T9TAOtherBLUE PLUS
MNHP36359OtherHEALTHPARTNERS
MN410002031Medicaid