Provider Demographics
NPI:1275772006
Name:JEFFERSON CORNELIUS, CAROLYN LAURICE (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:LAURICE
Last Name:JEFFERSON CORNELIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:L
Other - Last Name:CORNELIUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2764 N GREEN VALLEY PKWY
Mailing Address - Street 2:SUITE 504
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2120
Mailing Address - Country:US
Mailing Address - Phone:702-528-1668
Mailing Address - Fax:702-982-5672
Practice Address - Street 1:3131 LA CANADA ST
Practice Address - Street 2:SUITE 241
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-2578
Practice Address - Country:US
Practice Address - Phone:702-693-6870
Practice Address - Fax:702-693-6899
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12973207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1275772006Medicaid
NV1275772006Medicaid