Provider Demographics
NPI:1689665861
Name:CORNETTA, JAMES VINCENT (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:VINCENT
Last Name:CORNETTA
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 1:226 FORT LN
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2220
Mailing Address - Country:US
Mailing Address - Phone:757-393-6131
Mailing Address - Fax:757-939-0976
Practice Address - Street 1:226 FORT LN
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2220
Practice Address - Country:US
Practice Address - Phone:757-393-6131
Practice Address - Fax:757-393-0976
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000158152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010284716Medicaid
VA25072OtherOPTIMA
VA178555OtherANTHEM BCBS
VAU21005Medicare UPIN
VA25072OtherOPTIMA
VA010284716Medicaid
VA410001077Medicare PIN