Provider Demographics
NPI:1679572432
Name:CORNEJO, JOSE A (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:CORNEJO
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 1:5729 MASTERS CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4023
Mailing Address - Country:US
Mailing Address - Phone:407-876-4791
Mailing Address - Fax:407-240-7693
Practice Address - Street 1:5636 HANSEL AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4216
Practice Address - Country:US
Practice Address - Phone:407-850-0056
Practice Address - Fax:407-240-7693
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029540208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD21607Medicare UPIN
FL47392ZMedicare ID - Type Unspecified