Provider Demographics
NPI:1174613400
Name:CORNWALL, JOHN WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALLACE
Last Name:CORNWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 CENTRAL PARK W # 1-DB
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6003
Mailing Address - Country:US
Mailing Address - Phone:212-799-0630
Mailing Address - Fax:212-799-4266
Practice Address - Street 1:55 CENTRAL PARK W # 1-DB
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-6003
Practice Address - Country:US
Practice Address - Phone:212-799-0630
Practice Address - Fax:212-799-4266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY26A131Medicare PIN
CO7384Medicare UPIN