Provider Demographics
NPI:1215990981
Name:CORNWELL, RONALD WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:WILLIAM
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-2700
Mailing Address - Fax:208-302-2725
Practice Address - Street 1:4400 E FLAMINGO AVE
Practice Address - Street 2:STE 200
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-302-2700
Practice Address - Fax:208-302-2725
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6572208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003627000Medicaid
ID1133465Medicare ID - Type Unspecified
IDF86790Medicare UPIN
ID000010001100OtherREGENCE BLUE SHIELD