Provider Demographics
NPI:1568448025
Name:CORNWELL, ROBERT R (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:CORNWELL
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:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-2591
Mailing Address - Fax:920-320-4155
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-9662
Practice Address - Country:US
Practice Address - Phone:920-320-6212
Practice Address - Fax:920-684-5548
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00835713OtherRR MEDICARE
WI207R00000XMedicaid
WI1568448025OtherBCBS
WI002438235Medicare PIN
WI207R00000XMedicaid