Healthcare Provider Details

I. General information

NPI: 1447415161
Provider Name (Legal Business Name): GEOFFREY DEE CORNELSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

IV. Provider business mailing address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-6700
  • Fax: 928-532-2157
Mailing address:
  • Phone: 928-537-6700
  • Fax: 928-532-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberOS015070
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number56152
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOT012680
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number006377
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: