Provider Demographics
NPI:1235269937
Name:CORNEJO, ANDRES (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2303
Mailing Address - Country:US
Mailing Address - Phone:847-255-4831
Mailing Address - Fax:
Practice Address - Street 1:215 N FOREST AVE
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2303
Practice Address - Country:US
Practice Address - Phone:847-255-4831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL281P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL847-10-58-0056OtherMEDICAL EDUCATION
ILAC1389685OtherDEA
ILC41086Medicare UPIN
ILAC1389685OtherDEA