Healthcare Provider Details

I. General information

NPI: 1194722512
Provider Name (Legal Business Name): CRAIG ALLEN KORNICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7207 GOLDEN WINGS ROAD
JACKSONVILLE FL
32244
US

IV. Provider business mailing address

7207 GOLDEN WINGS ROAD
JACKSONVILLE FL
32244-2004
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-1010
  • Fax: 904-389-1082
Mailing address:
  • Phone: 904-389-1010
  • Fax: 904-389-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME82614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: