Provider Demographics
NPI:1205867611
Name:CORNELLA-CARLSON, CURTIS L (DO)
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:L
Last Name:CORNELLA-CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:3289 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222
Practice Address - Country:US
Practice Address - Phone:414-771-7900
Practice Address - Fax:414-607-6336
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45926207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43508400Medicaid
WIP00823715OtherRR MEDICARE
WI46236-0074Medicare PIN
F59852Medicare UPIN
WI43508400Medicaid