Provider Demographics
NPI:1093060733
Name:CORNEJO, ADAM JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:JOSEPH
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 VISTA DEL REY NE UNIT 8A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2195
Mailing Address - Country:US
Mailing Address - Phone:505-596-1852
Mailing Address - Fax:
Practice Address - Street 1:1804 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-596-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
NMPOD410213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No174H00000XOther Service ProvidersHealth Educator