MEDICARE: JOSE A CORNEJO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	ME0029540	FL

General Provider Information

NPI Number	:	1679572432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE A CORNEJO M.D.

Provider Business Mailing Address
First Line	:	5729 MASTERS CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-4023
Country	:	US
Telephone Number	:	407-876-4791
Fax Number	:	407-240-7693

Provider Business Practice Location Address
First Line	:	5636 HANSEL AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-4216
Country	:	US
Telephone Number	:	407-850-0056
Fax Number	:	407-240-7693

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/08/2007

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