Provider Demographics
NPI:1194807503
Name:CORNACCHIONE, MARIO (DO)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:CORNACCHIONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 ALEEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAR CREEK TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18702-9611
Mailing Address - Country:US
Mailing Address - Phone:570-829-1095
Mailing Address - Fax:570-331-3584
Practice Address - Street 1:1627 CHEW ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3648
Practice Address - Country:US
Practice Address - Phone:610-969-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005253L207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA446696Medicare ID - Type Unspecified