Provider Demographics
NPI:1275662140
Name:CORNFORTH, GREG B (PT)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:B
Last Name:CORNFORTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2314
Mailing Address - Country:US
Mailing Address - Phone:276-623-2128
Mailing Address - Fax:276-889-4026
Practice Address - Street 1:395 HIGHLAND DR.
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-889-4090
Practice Address - Fax:276-889-4026
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005530225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4979711Medicaid