Provider Demographics
NPI:1487653515
Name:KORNILOW, JAN ROMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:ROMAN
Last Name:KORNILOW
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:260-969-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046719A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000658168OtherANTHEM BC/BS
IN200173100AMedicaid
INP00742238OtherRAILROAD MEDICARE
IN000000626585OtherANTHEM BC/BS
INP00841049OtherRAILROAD MEDICARE
IN000000082488OtherBLUE CROSS/BLUE SHIELD
INP00730932OtherRAILROAD MEDICARE
INP00841049OtherRAILROAD MEDICARE
ING67472Medicare UPIN
IN200173100AMedicaid
INP00730932OtherRAILROAD MEDICARE
INM400058016Medicare PIN
IN203170PMedicare PIN
IN261920GMedicare PIN