Provider Demographics
NPI:1336205939
Name:BROOKFIELD PODIATRY
Entity Type:Organization
Organization Name:BROOKFIELD PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-740-8637
Mailing Address - Street 1:246 FEDERAL RD
Mailing Address - Street 2:SUITE C-21
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2647
Mailing Address - Country:US
Mailing Address - Phone:203-740-8637
Mailing Address - Fax:203-740-8750
Practice Address - Street 1:246 FEDERAL RD
Practice Address - Street 2:SUITE C-21
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2647
Practice Address - Country:US
Practice Address - Phone:203-740-8637
Practice Address - Fax:203-740-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000514213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT030000514CT01OtherBLUE CROSS BLUE SHIELD
CT4902110001Medicare NSC
CT030000514CT01OtherBLUE CROSS BLUE SHIELD