Healthcare Provider Details

I. General information

NPI: 1093060733
Provider Name (Legal Business Name): ADAM JOSEPH CORNEJO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 CARLISLE BLVD NE
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

2900 VISTA DEL REY NE UNIT 8A
ALBUQUERQUE NM
87112-2195
US

V. Phone/Fax

Practice location:
  • Phone: 505-596-1852
  • Fax:
Mailing address:
  • Phone: 505-596-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD410
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: