Provider Demographics
NPI:1245470319
Name:CORNEJO, EDWARD (PT, MPT, CFMT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:PT, MPT, CFMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11240
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1240
Mailing Address - Country:US
Mailing Address - Phone:714-307-6640
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE J108
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7919
Practice Address - Country:US
Practice Address - Phone:714-307-6640
Practice Address - Fax:949-612-3821
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA285062251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist