Provider Demographics
NPI:1619292455
Name:CORNELIUS, BRANDON CHASE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:CHASE
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 LUTHER LN # 329
Mailing Address - Street 2:OB HOSPITALISTS OF TEXAS
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:214-594-7684
Practice Address - Street 1:3410 WORTH ST STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2092
Practice Address - Country:US
Practice Address - Phone:214-370-1300
Practice Address - Fax:214-370-1313
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9544207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX334772603Medicaid