Basic Information
| Provider Information | |||||||||
| NPI: | 1174919948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORBETT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 701 TECH CENTER DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432301987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149444800 | ||||||||
| FaxNumber: | 6149444750 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W WILSON BRIDGE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430852590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147962900 | ||||||||
| FaxNumber: | 6147962901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35.139297 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0402520 | 05 | OH | MEDICAID |