Provider Demographics
NPI:1417010448
Name:VANDERZIEL, CORNELIA (MD)
Entity Type:Individual
Prefix:
First Name:CORNELIA
Middle Name:
Last Name:VANDERZIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4302
Practice Address - Country:US
Practice Address - Phone:617-661-5585
Practice Address - Fax:617-661-5107
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52836207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA052836OtherTUFTS HEALTH PLAN
MA0014780OtherNEIGHBORHOOD HEALTH PLAN
MAG179OtherHARVARD PILGRIM
MA3179931Medicaid
MAJ03754OtherBCBS MA
MA0233445-002OtherCIGNA HEALTH CARE
MAG179OtherHARVARD PILGRIM
MA052836OtherTUFTS HEALTH PLAN