1669884987 NPI number — DR. JAMES NELSON CORNWELL D.O.

Table of content: DR. JAMES NELSON CORNWELL D.O. (NPI 1669884987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669884987 NPI number — DR. JAMES NELSON CORNWELL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNWELL
Provider First Name:
JAMES
Provider Middle Name:
NELSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669884987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
514 PLAZA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAND SPRINGS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74063-7915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-215-5100
Provider Business Mailing Address Fax Number:
918-215-5105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 PLAZA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAND SPRINGS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-215-5100
Provider Business Practice Location Address Fax Number:
918-215-5105
Provider Enumeration Date:
05/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  6310 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 675798 . This is a "MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200769410A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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