Healthcare Provider Details

I. General information

NPI: 1275915753
Provider Name (Legal Business Name): NATHAN A CORNISH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number287591
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number287591
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MB12630500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: