Provider Demographics
NPI:1467765982
Name:CORNELIO, DEMETRIO SANTIAGO (PT)
Entity Type:Individual
Prefix:MR
First Name:DEMETRIO
Middle Name:SANTIAGO
Last Name:CORNELIO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-3625
Mailing Address - Country:US
Mailing Address - Phone:347-657-0162
Mailing Address - Fax:
Practice Address - Street 1:1818 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-3625
Practice Address - Country:US
Practice Address - Phone:347-657-0162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017865225100000X, 2251G0304X, 2251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic