Provider Demographics
NPI:1629851886
Name:CORNWALL, KENNETH DAVID (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:CORNWALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 PACES FERRY RD SE APT 413
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-7639
Mailing Address - Country:US
Mailing Address - Phone:404-783-2208
Mailing Address - Fax:
Practice Address - Street 1:3240 S COBB DR SE STE 1000
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4112
Practice Address - Country:US
Practice Address - Phone:770-701-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003524152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist