Provider Demographics
NPI:1376633826
Name:CORNWALL, ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:CORNWALL
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 1:3333 BURNET AVE
Mailing Address - Street 2:ML 2017
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4454
Mailing Address - Fax:513-636-3928
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 2017
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4454
Practice Address - Fax:513-636-3928
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422463207X00000X
OH35.092493207XP3100X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100849367Medicaid
PA100849367Medicaid
PAH70327Medicare UPIN