Provider Demographics
NPI:1821298001
Name:CORNETT, BENJAMIN L (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:CORNETT
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 1:500 W FORT ST
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1325
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1325
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429680207P00000X
IDM-10326207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808073400Medicaid
PA1019649260001Medicaid
OH2791635Medicaid
WV3810009527Medicaid
ID808073400Medicaid
PA113523GXFMedicare PIN
OH2791635Medicaid