Provider Demographics
NPI:1477552354
Name:CORNELL, ROY BRADFORD (MD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:BRADFORD
Last Name:CORNELL
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 1:2801 NEW HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1320
Mailing Address - Country:US
Mailing Address - Phone:270-683-3720
Mailing Address - Fax:270-686-7331
Practice Address - Street 1:2801 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1320
Practice Address - Country:US
Practice Address - Phone:270-683-3720
Practice Address - Fax:270-686-7331
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30382208600000X, 2086S0129X
IN01047053A208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
611059472OtherUMWA
IN611059472110OtherCARESOURCE
IN200139790Medicaid
020037451OtherRAILROAD MEDICARE
KY000000048408OtherANTHEM
IN200139790OtherMOLINA
611059472OtherDART
KY64303829Medicaid
IN611059472110OtherCARESOURCE
IN200139790Medicaid
KY64303829Medicaid