Provider Demographics
NPI:1972786812
Name:CORNWELL, DONALD GENE (DOM LMT PHD)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:GENE
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:DOM LMT PHD
Other - Prefix:MR
Other - First Name:DON
Other - Middle Name:
Other - Last Name:CORNWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOM LMT PHD
Mailing Address - Street 1:202 MORNINGSIDE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2633
Mailing Address - Country:US
Mailing Address - Phone:505-268-6870
Mailing Address - Fax:505-268-0818
Practice Address - Street 1:202 MORNINGSIDE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2633
Practice Address - Country:US
Practice Address - Phone:505-268-6870
Practice Address - Fax:505-268-0818
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM210171100000X
NM0668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist