Provider Demographics
NPI:1750331443
Name:CORNWALL, CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:CORNWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GILL ST
Mailing Address - Street 2:STE 3000
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1728
Mailing Address - Country:US
Mailing Address - Phone:781-937-4522
Mailing Address - Fax:
Practice Address - Street 1:27 PARK ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5230
Practice Address - Country:US
Practice Address - Phone:508-862-5981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150340207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ17570OtherBLUE SHIELD
MA3163598Medicaid
MAJ17570OtherBLUE SHIELD
MA930107150Medicare PIN
MA3163598Medicaid
MAQX9757Medicare PIN