Provider Demographics
NPI:1881773018
Name:CORNELL, BRIAN WILLIAM (DPM)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:CORNELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MEMORIAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-3679
Mailing Address - Country:US
Mailing Address - Phone:401-846-2800
Mailing Address - Fax:401-849-4899
Practice Address - Street 1:55 MEMORIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-3679
Practice Address - Country:US
Practice Address - Phone:401-846-2800
Practice Address - Fax:401-849-4899
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00195213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9007121Medicaid
RI2700178OtherUNITED HEALTHCARE
RI71215OtherBLUE CROSS BLUE SHIELD
RI9007121Medicaid