Healthcare Provider Details

I. General information

NPI: 1952568974
Provider Name (Legal Business Name): JUAN CARLOS CORNEJO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WHITE HORSE RD W SUITE 7
VOORHEES NJ
08043-3672
US

IV. Provider business mailing address

113 WHITE HORSE RD W SUITE 7
VOORHEES NJ
08043-3672
US

V. Phone/Fax

Practice location:
  • Phone: 856-552-2208
  • Fax: 856-283-3158
Mailing address:
  • Phone: 856-552-2208
  • Fax: 856-283-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB08477000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberH0072462
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102202824
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS014255
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: