Provider Demographics
NPI:1821122342
Name:CORNETT, JOHN CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CRAIG
Last Name:CORNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:CRAIG
Other - Last Name:CORNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1241 ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70116-1947
Mailing Address - Country:US
Mailing Address - Phone:504-361-3041
Mailing Address - Fax:504-361-3005
Practice Address - Street 1:1125 NEWTON ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-6339
Practice Address - Country:US
Practice Address - Phone:504-361-3041
Practice Address - Fax:504-361-3005
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07490R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1376329Medicaid