Basic Information
| Provider Information | |||||||||
| NPI: | 1740271881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 740608 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753740608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693179900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14679 MIDWAY RD STE 206 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693179900 | ||||||||
| FaxNumber: | 9722167346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G0384 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 122597103 | 05 | TX | MEDICAID | 88R744 | 01 | TX | BCBS | OTHER | B006 | 01 | TX | CHAMPUS | OTHER |