Provider Demographics
NPI:1639149271
Name:CORNETTE, GARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:CORNETTE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6913 W 123RD TER APT 705
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2822
Mailing Address - Country:US
Mailing Address - Phone:928-864-8042
Mailing Address - Fax:
Practice Address - Street 1:6913 W 123RD TER APT 705
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2822
Practice Address - Country:US
Practice Address - Phone:928-864-8042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002889A207RG0100X
MO2021047585207RG0100X
KS05-23660207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200064410Medicaid
IN184520MMMedicare ID - Type Unspecified
IN200064410Medicaid