Provider Demographics
NPI:1740271881
Name:CORNELL, THOMAS JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
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:PO BOX 740608
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-0608
Mailing Address - Country:US
Mailing Address - Phone:469-317-9900
Mailing Address - Fax:
Practice Address - Street 1:14679 MIDWAY RD STE 206
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3197
Practice Address - Country:US
Practice Address - Phone:469-317-9900
Practice Address - Fax:972-216-7346
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG03842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122597103Medicaid
TX88R744OtherBCBS
TXB006OtherCHAMPUS
TX88R744OtherBCBS
TXB21973Medicare UPIN