Provider Demographics
NPI:1164455481
Name:CORN, STEPHANIE (MD, FAAP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CORN
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 NORTH GROVE ST
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533
Mailing Address - Country:US
Mailing Address - Phone:706-864-6700
Mailing Address - Fax:706-864-2599
Practice Address - Street 1:1055 NORTH GROVE ST
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533
Practice Address - Country:US
Practice Address - Phone:706-864-6700
Practice Address - Fax:706-864-2599
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033810208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F21404Medicare UPIN