Provider Demographics
NPI:1174713564
Name:VAN DE WEGE, CORBIN (MD)
Entity type:Individual
Prefix:DR
First Name:CORBIN
Middle Name:
Last Name:VAN DE WEGE
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:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:2750 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3506
Practice Address - Country:US
Practice Address - Phone:417-269-2281
Practice Address - Fax:417-269-2292
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007018558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO623949OtherANTHEM