Provider Demographics
NPI:1083131734
Name:CORNISH, BRENT
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:CORNISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 S MIDWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4727
Mailing Address - Country:US
Mailing Address - Phone:405-503-0679
Mailing Address - Fax:
Practice Address - Street 1:613 S MIDWEST BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4727
Practice Address - Country:US
Practice Address - Phone:405-503-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicaid