Healthcare Provider Details

I. General information

NPI: 1003884339
Provider Name (Legal Business Name): RAYMOND L CORNELISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W IOWA AVE
CHICKASHA OK
73018-2738
US

IV. Provider business mailing address

2222 W IOWA AVE
CHICKASHA OK
73018-2738
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-8111
  • Fax: 405-594-0708
Mailing address:
  • Phone: 405-224-8111
  • Fax: 405-594-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number9074
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number9074
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: