Provider Demographics
NPI:1255408365
Name:CORNIELLE, JORGE LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:CORNIELLE
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 1:102 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1026
Mailing Address - Country:US
Mailing Address - Phone:845-398-3043
Mailing Address - Fax:
Practice Address - Street 1:1262 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3602
Practice Address - Country:US
Practice Address - Phone:718-617-2500
Practice Address - Fax:718-617-0500
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02087341Medicaid