Provider Demographics
NPI:1568578862
Name:CORNEJO, CHRISTIAN LY (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:LY
Last Name:CORNEJO
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 1:601 S CARLIN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1044
Mailing Address - Country:US
Mailing Address - Phone:703-271-8800
Mailing Address - Fax:703-271-8585
Practice Address - Street 1:508 KENNEDY ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-3010
Practice Address - Country:US
Practice Address - Phone:202-545-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240007208000000X
DCMD038358208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101240007OtherMEDICAL LICENSE
VA010290988Medicaid