Provider Demographics
NPI:1154514446
Name:MARCUS CORNWALL, DOPC
Entity type:Organization
Organization Name:MARCUS CORNWALL, DOPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:H
Authorized Official - Last Name:CORNWALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-233-5273
Mailing Address - Street 1:6542 SE LAKE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:503-233-5273
Mailing Address - Fax:855-492-8902
Practice Address - Street 1:6542 SE LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2245
Practice Address - Country:US
Practice Address - Phone:503-233-5273
Practice Address - Fax:855-492-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23052261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR132205Medicare PIN