Provider Demographics
NPI:1275507956
Name:KORNILOW, JERZY STANISLAW (OD)
Entity Type:Individual
Prefix:
First Name:JERZY
Middle Name:STANISLAW
Last Name:KORNILOW
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 1:1051 E MAIN ST
Mailing Address - Street 2:STE 7
Mailing Address - City:WAYNESBORO
Mailing Address - State:PA
Mailing Address - Zip Code:17268-2318
Mailing Address - Country:US
Mailing Address - Phone:301-791-0888
Mailing Address - Fax:301-791-3611
Practice Address - Street 1:251 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6144
Practice Address - Country:US
Practice Address - Phone:301-791-0888
Practice Address - Fax:301-791-3611
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1369152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U61401Medicare UPIN