Provider Demographics
NPI:1841279403
Name:KORNACKI, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:KORNACKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HORATIO ST
Mailing Address - Street 2:APT 4M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-1608
Mailing Address - Country:US
Mailing Address - Phone:212-691-6310
Mailing Address - Fax:
Practice Address - Street 1:2 HORATIO ST
Practice Address - Street 2:APT 4M
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-1608
Practice Address - Country:US
Practice Address - Phone:212-691-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1959361207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF66229Medicare UPIN