Basic Information
| Provider Information | |||||||||
| NPI: | 1952668220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUM | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | JONATHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6355 S BUFFALO DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891132133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10105 BANBURRY CROSS DR STE 460 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891446645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023607600 | ||||||||
| FaxNumber: | 7023633814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0001X | DOS-1665 | HI | N | 207RC0000X | DOS-1665 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | DO3065 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | DO3065 | NV | Y |
ID Information
| ID | Type | State | Issuer | Description | 819493 | 05 | HI | MEDICAID | DO03065 | 01 | NV | STATE LICENSE | OTHER |