Provider Demographics
NPI:1316065204
Name:RUPERTO, CORNELIO RODERICK (MD)
Entity type:Individual
Prefix:DR
First Name:CORNELIO
Middle Name:RODERICK
Last Name:RUPERTO
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 1:350 PILOT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-8119
Mailing Address - Country:US
Mailing Address - Phone:336-945-0345
Mailing Address - Fax:336-945-0342
Practice Address - Street 1:6620 SHALLOWFORD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9504
Practice Address - Country:US
Practice Address - Phone:336-945-0345
Practice Address - Fax:336-945-0342
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-017322084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900260Medicaid
NC2022436Medicare PIN
NC5900260Medicaid