Provider Demographics
NPI:1780034090
Name:CORNELL, JASON CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CHRISTOPHER
Last Name:CORNELL
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 1:602 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4918
Mailing Address - Country:US
Mailing Address - Phone:616-546-4950
Mailing Address - Fax:
Practice Address - Street 1:602 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4918
Practice Address - Country:US
Practice Address - Phone:616-546-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068764207R00000X
MI4301118983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine