Provider Demographics
NPI:1730362799
Name:CORNICELLI, DIANE M (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:CORNICELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7123 PEARL RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-4944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18101 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5612
Practice Address - Country:US
Practice Address - Phone:216-476-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-056746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0784414Medicaid
OH0657668Medicare PIN