Provider Demographics
NPI:1861593402
Name:CORBIN, KENNETH L (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:CORBIN
Suffix:
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 PROFESSIONAL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3752
Practice Address - Country:US
Practice Address - Phone:916-536-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3595228OtherCIGNA
CA44312OtherINTERPLAN
CA90015756OtherPACIFICARE
CAC38454OtherBLUE CROSS
CA00C384540OtherBLUE SHIELD
CA019553OtherHEALTH NET
CA13175OtherFIRST HEALTH
CA000810342925OtherPHCS
CA1092253OtherGREAT WEST
CAMCMG124300OtherWESTERN HEALTH ADVANTAGE
CA00C384540Medicaid
CA1452864OtherUNITED HEALTHCARE
CA4507543OtherAETNA
CA90015756OtherPACIFICARE
CA44312OtherINTERPLAN