Provider Demographics
NPI:1720547045
Name:CORNWELL, BRANDON (DO)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CORNWELL
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 1:4201 ST. ANTOINE
Mailing Address - Street 2:UHC-9C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE
Practice Address - Street 2:UHC-9C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-5147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-16
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program