Provider Demographics
NPI:1750405585
Name:PETER J CORNELL MD INC
Entity type:Organization
Organization Name:PETER J CORNELL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-274-9205
Mailing Address - Street 1:450 N BEDFORD DR
Mailing Address - Street 2:STE 101
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4324
Mailing Address - Country:US
Mailing Address - Phone:310-274-9205
Mailing Address - Fax:310-274-7229
Practice Address - Street 1:450 N BEDFORD DR
Practice Address - Street 2:STE 101
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4324
Practice Address - Country:US
Practice Address - Phone:310-274-9205
Practice Address - Fax:310-274-7229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0007690Medicaid
CAW3506Medicare PIN
CAGR0007690Medicaid