Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 9074 | OK |
N | 207ND0900X | Dermatopathologist | 9074 | OK |
NPI | 1003884339 |
---|---|
Provider Name | Raymond L Cornelison |
First Address | Oklahoma City, OK 73126-8988 |
Second Address | Oklahoma City, OK 73116-1923 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2006 |
Last Update Date | 23/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1528364304 | GROUP NPI (01) | OK |