Provider Demographics
NPI:1003884339
Name:CORNELISON, RAYMOND L (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:L
Last Name:CORNELISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268988
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8988
Mailing Address - Country:US
Mailing Address - Phone:405-608-4494
Mailing Address - Fax:405-608-4504
Practice Address - Street 1:3727 NW 63RD ST STE 205
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1923
Practice Address - Country:US
Practice Address - Phone:405-608-4494
Practice Address - Fax:405-608-4504
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-11
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9074207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1528364304OtherGROUP NPI
OK1528364304OtherGROUP NPI