Provider Demographics
NPI:1467500751
Name:CORNELIUS, JOHN THOR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOR
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1317 H ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-1906
Mailing Address - Country:US
Mailing Address - Phone:976-616-5531
Mailing Address - Fax:916-440-1512
Practice Address - Street 1:1400 A ST BLDG A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-0631
Practice Address - Country:US
Practice Address - Phone:916-440-1500
Practice Address - Fax:916-440-1512
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA799572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0TH000Medicare UPIN