Healthcare Provider Details

I. General information

NPI: 1417936550
Provider Name (Legal Business Name): DAMIAN CORNACCHIA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax: 484-565-1513
Mailing address:
  • Phone: 484-565-1510
  • Fax: 484-565-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS005634L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: