Provider Demographics
NPI:1417936550
Name:CORNACCHIA, DAMIAN (DO)
Entity Type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:CORNACCHIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1763
Mailing Address - Country:US
Mailing Address - Phone:484-565-1510
Mailing Address - Fax:484-565-1513
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:484-565-1510
Practice Address - Fax:484-565-1513
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005634L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE84369Medicare UPIN
PA23-2359401OtherMAIN LINE HEALTHCARE TIN
PAE84369Medicare UPIN
PA614991RNJMedicare PIN