1740253053 NPI number — WILSON JASON CORNETT MD

Table of content: WILSON JASON CORNETT MD (NPI 1740253053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740253053 NPI number — WILSON JASON CORNETT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNETT
Provider First Name:
WILSON
Provider Middle Name:
JASON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1740253053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 LAKELAND HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33805-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-680-7000
Provider Business Mailing Address Fax Number:
866-264-8519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 LAKELAND HILLS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805-3202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-680-7337
Provider Business Practice Location Address Fax Number:
863-680-7331
Provider Enumeration Date:
02/08/2006

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: 208000000X , with the licence number:  ME79345 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 261461800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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