Basic Information
| Provider Information | |||||||||
| NPI: | 1295964153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORPUS | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 MOCKINGBIRD LN | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717302837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708758838 | ||||||||
| FaxNumber: | 8708758838 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 THOMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717304569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708624216 | ||||||||
| FaxNumber: | 8708629011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2009 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | E-7213 | AR | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 207Q00000X | E-7213 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01082504 | 01 | AR | RAILROAD MEDICARE | OTHER | 194054001 | 05 | AR | MEDICAID |