Provider Demographics
NPI:1174525992
Name:CORNELIUS, LISA ANN (DPM)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 NW SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3784
Mailing Address - Country:US
Mailing Address - Phone:541-757-7100
Mailing Address - Fax:541-757-7101
Practice Address - Street 1:3640 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3784
Practice Address - Country:US
Practice Address - Phone:541-757-7100
Practice Address - Fax:541-757-7101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00209213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR121001Medicare ID - Type Unspecified
U13857Medicare UPIN