Provider Demographics
NPI:1003873423
Name:CORNETT, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:CORNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:315 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1703
Mailing Address - Country:US
Mailing Address - Phone:502-629-2500
Mailing Address - Fax:502-629-3165
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1703
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-3165
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY289892085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1757375OtherCIGNA PROVIDER NUMBER
KY920005753OtherRAILROAD MEDICARE
KY000000178939OtherANTHEM PROVIDER NUMB
KY1118125OtherPASSPORTPROVIDER NUMB
KY64289895Medicaid
KY000020583JOtherHUMANA PROVIDER NUMB
IN200035990Medicaid
KY5941087OtherAETNA PROVIDER NUMB
KY5941087OtherAETNA PROVIDER NUMB
KY64289895Medicaid