1972786812 NPI number — MR. DONALD GENE CORNWELL DOM LMT PHD

Table of content: MR. DONALD GENE CORNWELL DOM LMT PHD (NPI 1972786812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972786812 NPI number — MR. DONALD GENE CORNWELL DOM LMT PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNWELL
Provider First Name:
DONALD
Provider Middle Name:
GENE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DOM LMT PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORNWELL
Provider Other First Name:
DON
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DOM LMT PHD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1972786812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 MORNINGSIDE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87108-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-268-6870
Provider Business Mailing Address Fax Number:
505-268-0818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 MORNINGSIDE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87108-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-268-6870
Provider Business Practice Location Address Fax Number:
505-268-0818
Provider Enumeration Date:
12/14/2007

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: 171100000X , with the licence number:  210 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225700000X , with the licence number: 0668 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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