Provider Demographics
NPI:1306908132
Name:CORNELL, JAN GORDON (MD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:GORDON
Last Name:CORNELL
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:PO BOX 746071
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6071
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:1431 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1411
Practice Address - Country:US
Practice Address - Phone:937-348-7001
Practice Address - Fax:937-949-6113
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070166 A207Q00000X
OH35.129685207Q00000X
NMMD2008-0712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201035040Medicaid
OH0067258Medicaid
000000734290OtherANTHEM
IN259370145Medicare PIN
INM400054903Medicare PIN
MI4296969Medicaid