Provider Demographics
NPI:1669643383
Name:LISA A. CORNELIUS DPM PC
Entity Type:Organization
Organization Name:LISA A. CORNELIUS DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-757-7100
Mailing Address - Street 1:3640 NW SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3784
Mailing Address - Country:US
Mailing Address - Phone:541-757-7100
Mailing Address - Fax:541-757-7101
Practice Address - Street 1:3640 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3784
Practice Address - Country:US
Practice Address - Phone:541-757-7100
Practice Address - Fax:541-757-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00209213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR021324Medicaid
ORR121001Medicare PIN