Healthcare Provider Details

I. General information

NPI: 1255317475
Provider Name (Legal Business Name): CORNEL C VAN GORP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 W HIGH ST
BRYAN OH
43506-1681
US

IV. Provider business mailing address

5052 N CLINTON ST
FORT WAYNE IN
46825-5822
US

V. Phone/Fax

Practice location:
  • Phone: 419-636-4517
  • Fax:
Mailing address:
  • Phone: 260-484-8551
  • Fax: 260-482-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number35075876
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: