Healthcare Provider Details

I. General information

NPI: 1285734327
Provider Name (Legal Business Name): FLAVIO CORNEJO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550A WATER ST
SANTA CRUZ CA
95060
US

IV. Provider business mailing address

550A WATER ST
SANTA CRUZ CA
95060
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-0420
  • Fax: 831-425-0185
Mailing address:
  • Phone: 831-425-0420
  • Fax: 831-425-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: