Provider Demographics
NPI:1447426424
Name:CORNELIUS, ANDREW LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:LEWIS
Last Name:CORNELIUS
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 1:673D MDG, 5955 ZEAMER AVENUE
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-1571
Mailing Address - Fax:907-580-1575
Practice Address - Street 1:673D MDG, 5955 ZEAMER AVENUE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-1571
Practice Address - Fax:907-580-1575
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT193729207X00000X
PAMD440780207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT193729OtherGRADUATE MEDICAL TRAINEE