Provider Demographics
NPI:1619946969
Name:CORNELIUS, MATTHEW C (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:CORNELIUS
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 1:1300 N 12TH ST STE 320
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-521-3605
Mailing Address - Fax:602-521-3601
Practice Address - Street 1:1300 N 12TH ST STE 320
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-521-3605
Practice Address - Fax:602-521-3601
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ244092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480020Medicaid
AZ480020Medicaid
Z74595Medicare PIN