Provider Demographics
NPI:1811997398
Name:CORNISH, DWIGHT J (PT)
Entity type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:J
Last Name:CORNISH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13888
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92255-3888
Mailing Address - Country:US
Mailing Address - Phone:760-568-9811
Mailing Address - Fax:760-568-9866
Practice Address - Street 1:74399 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4116
Practice Address - Country:US
Practice Address - Phone:760-568-9811
Practice Address - Fax:760-568-9866
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA7254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT72542Medicare ID - Type Unspecified