Healthcare Provider Details

I. General information

NPI: 1255408365
Provider Name (Legal Business Name): JORGE LUIS CORNIELLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 BOSTON RD
BRONX NY
10456-3602
US

IV. Provider business mailing address

102 PRINCETON DR
TAPPAN NY
10983-1026
US

V. Phone/Fax

Practice location:
  • Phone: 718-617-2500
  • Fax: 718-617-0500
Mailing address:
  • Phone: 845-398-3043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number214716
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: