Provider Demographics
NPI:1861655573
Name:CORNWELL, BENJAMIN OSBURN (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:OSBURN
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 274
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-5125
Mailing Address - Fax:405-271-3462
Practice Address - Street 1:940 NE 13TH ST
Practice Address - Street 2:4G4250
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5008
Practice Address - Country:US
Practice Address - Phone:405-271-5125
Practice Address - Fax:405-271-3462
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47482085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology