Provider Demographics
NPI:1396738613
Name:CORNWELL, MICHAEL JAMES (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:CORNWELL
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 1:2665 N DECATUR RD
Mailing Address - Street 2:STE. 730
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6149
Mailing Address - Country:US
Mailing Address - Phone:404-508-4320
Mailing Address - Fax:404-508-4112
Practice Address - Street 1:2665 N DECATUR RD
Practice Address - Street 2:STE. 730
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6149
Practice Address - Country:US
Practice Address - Phone:404-508-4320
Practice Address - Fax:404-508-4112
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG90417Medicare UPIN
GA02BDFWLMedicare ID - Type Unspecified