Provider Demographics
NPI:1730172453
Name:CORBISIERO, RAFFAELE M SR (MD)
Entity type:Individual
Prefix:MR
First Name:RAFFAELE
Middle Name:M
Last Name:CORBISIERO
Suffix:SR
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 1:210S GRAND AVE 407
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4290
Mailing Address - Country:US
Mailing Address - Phone:626-914-5051
Mailing Address - Fax:626-914-5068
Practice Address - Street 1:210S GRAND AVE 407
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4290
Practice Address - Country:US
Practice Address - Phone:626-914-5051
Practice Address - Fax:626-914-5068
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48113208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A481131Medicaid
E96657Medicare UPIN
CA00A481131Medicaid
A48113Medicare ID - Type Unspecified