1841338175 NPI number — DR. CLIFFORD W CORNELIUS DDS

Table of content: DR. CLIFFORD W CORNELIUS DDS (NPI 1841338175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841338175 NPI number — DR. CLIFFORD W CORNELIUS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNELIUS
Provider First Name:
CLIFFORD
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1841338175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3150 N SWAN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-745-6531
Provider Business Mailing Address Fax Number:
520-790-3817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3150 N SWAN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-745-6531
Provider Business Practice Location Address Fax Number:
520-790-3817
Provider Enumeration Date:
02/01/2007

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: 204E00000X , with the licence number:  5116 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 510976 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ5116 . This is a "DELTA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0472930 . This is a "BLUE CROSS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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