Healthcare Provider Details

I. General information

NPI: 1003873423
Provider Name (Legal Business Name): MARK S CORNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4123 DUTCHMANS LN STE G2
LOUISVILLE KY
40207-4758
US

IV. Provider business mailing address

PO BOX 776347
CHICAGO IL
60677-6347
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-6601
  • Fax: 502-899-6644
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number28989
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: