Provider Demographics
NPI:1689639841
Name:CORNWALL, MARCUS H (DO)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:H
Last Name:CORNWALL
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 1:6975 SE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2103
Mailing Address - Country:US
Mailing Address - Phone:503-905-2526
Mailing Address - Fax:503-905-2545
Practice Address - Street 1:6975 SE LAKE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-2103
Practice Address - Country:US
Practice Address - Phone:503-905-2526
Practice Address - Fax:503-905-2545
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine