Provider Demographics
NPI:1063689727
Name:KORNIK, RACHEL I (MD)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:I
Last Name:KORNIK
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:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1234
Mailing Address - Country:US
Mailing Address - Phone:802-582-8239
Mailing Address - Fax:
Practice Address - Street 1:53 FAIRFAX RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-4405
Practice Address - Country:US
Practice Address - Phone:802-582-4900
Practice Address - Fax:802-782-8239
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0015116207N00000X
WI54704-20207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063689727Medicaid