Basic Information
| Provider Information | |||||||||
| NPI: | 1164482956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNETT | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42D MEDICAL GROUP | ||||||||
| Address2: | 300 S. TWINING ST. BLDG. 760 | ||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349533368 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Practice Location | |||||||||
| Address1: | 42D MEDICAL GROUP | ||||||||
| Address2: | 300 S. TWINING ST. BLDG. 760 | ||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349533368 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1679 | KS | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 18003253A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1679 | 01 | KS | OPTOMETRY LICENSE | OTHER | 18003253A | 01 | IN | OPTOMETRY LICENSE | OTHER |