Provider Demographics
NPI:1124254602
Name:MULDER, CORLYNE SUE (MD)
Entity type:Individual
Prefix:DR
First Name:CORLYNE
Middle Name:SUE
Last Name:MULDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CORLYNE
Other - Middle Name:SUE
Other - Last Name:LIEBENTHAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2357 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-6222
Mailing Address - Country:US
Mailing Address - Phone:630-859-6800
Mailing Address - Fax:
Practice Address - Street 1:1221 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1404
Practice Address - Country:US
Practice Address - Phone:630-859-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.134838207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036134838Medicaid
IL036134838Medicaid
IL390361Medicare PIN
IL0727500009Medicare NSC