Provider Demographics
NPI:1831225887
Name:JIM CORNWELL O.D.
Entity type:Organization
Organization Name:JIM CORNWELL O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-240-2406
Mailing Address - Street 1:5501 KAVANAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4614
Mailing Address - Country:US
Mailing Address - Phone:501-240-2406
Mailing Address - Fax:
Practice Address - Street 1:5501 KAVANAUGH BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-4614
Practice Address - Country:US
Practice Address - Phone:501-240-2406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2344152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48855OtherBLUE CROSS BLUE SHIELD
AR48855OtherBLUE CROSS BLUE SHIELD
AR48855Medicare ID - Type Unspecified