Provider Demographics
NPI:1164467924
Name:KORNMEHL, CAROL L (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:KORNMEHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 SPRINGDALE RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2024
Mailing Address - Country:US
Mailing Address - Phone:856-751-9010
Mailing Address - Fax:
Practice Address - Street 1:2090 SPRINGDALE RD STE B
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2024
Practice Address - Country:US
Practice Address - Phone:856-751-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA050555002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0239003Medicaid
E54391Medicare UPIN
NJ556515Medicare PIN