Provider Demographics
NPI:1164482956
Name:CORNETT, JAMIE DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:DALE
Last Name:CORNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42D MEDICAL GROUP
Mailing Address - Street 2:300 S. TWINING ST. BLDG. 760
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36113
Mailing Address - Country:US
Mailing Address - Phone:334-953-3368
Mailing Address - Fax:334-953-8607
Practice Address - Street 1:42D MEDICAL GROUP
Practice Address - Street 2:300 S. TWINING ST. BLDG. 760
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36113
Practice Address - Country:US
Practice Address - Phone:334-953-3368
Practice Address - Fax:334-953-8607
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1679152W00000X
IN18003253A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1679OtherOPTOMETRY LICENSE
IN18003253AOtherOPTOMETRY LICENSE
U97743Medicare UPIN