Provider Demographics
NPI:1275693624
Name:CORNWALL, BRIAN STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:STEPHEN
Last Name:CORNWALL
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 1:6130A 190TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2721
Mailing Address - Country:US
Mailing Address - Phone:718-454-8484
Mailing Address - Fax:
Practice Address - Street 1:6130A 190TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2721
Practice Address - Country:US
Practice Address - Phone:718-454-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4273-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
39326Medicare UPIN