Provider Demographics
NPI:1275858466
Name:KORNFELD, BENJAMIN DYLAN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DYLAN
Last Name:KORNFELD
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 1:2530 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2492
Mailing Address - Country:US
Mailing Address - Phone:847-869-0892
Mailing Address - Fax:847-869-1070
Practice Address - Street 1:2530 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2492
Practice Address - Country:US
Practice Address - Phone:847-869-0892
Practice Address - Fax:847-869-1070
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.130951208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program