Provider Demographics
NPI:1265541098
Name:CORPUS, JUANITO REGUDO (MD)
Entity type:Individual
Prefix:MR
First Name:JUANITO
Middle Name:REGUDO
Last Name:CORPUS
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 1:1002 S 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873
Mailing Address - Country:US
Mailing Address - Phone:863-773-5039
Mailing Address - Fax:863-773-6490
Practice Address - Street 1:1002 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873
Practice Address - Country:US
Practice Address - Phone:863-773-5039
Practice Address - Fax:863-773-6490
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38139207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D53424Medicare UPIN
25041Medicare ID - Type Unspecified