Basic Information
| Provider Information | |||||||||
| NPI: | 1639270812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELIUS | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. KINCAID STREET | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 E. DIVISION STREET | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604247991 | ||||||||
| FaxNumber: | 3604284377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD00018397 | WA | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD2086 | AK | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1646405 | 05 | WA | MEDICAID | MD2086 | 05 | AK | MEDICAID |