Provider Demographics
NPI:1760868590
Name:CORNELIUS, LELAND R (MD)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:R
Last Name:CORNELIUS
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:PO BOX 720
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-0720
Mailing Address - Country:US
Mailing Address - Phone:731-659-3125
Mailing Address - Fax:
Practice Address - Street 1:17 1ST ST E
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:TN
Practice Address - Zip Code:38069-4426
Practice Address - Country:US
Practice Address - Phone:731-548-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine