Healthcare Provider Details

I. General information

NPI: 1245470319
Provider Name (Legal Business Name): EDWARD CORNEJO PT, MPT, CFMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DOVE ST STE 320
NEWPORT BEACH CA
92660-2489
US

IV. Provider business mailing address

1600 DOVE ST STE 320
NEWPORT BEACH CA
92660-2489
US

V. Phone/Fax

Practice location:
  • Phone: 949-629-5211
  • Fax: 949-785-3191
Mailing address:
  • Phone: 949-629-5211
  • Fax: 949-785-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28506
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number28506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: