Provider Demographics
NPI:1548250830
Name:CORNWELL, JAMES ROY (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROY
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-526-9355
Mailing Address - Fax:912-526-8622
Practice Address - Street 1:110 R T STANLEY SR PLACE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-5623
Practice Address - Country:US
Practice Address - Phone:912-526-9355
Practice Address - Fax:912-526-8622
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01953207Q00000X
SC39184207Q00000X
GA050608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1548250830Medicaid
SCP01701620OtherRAILROAD MEDICARE
SCG50608Medicaid
NC1548250830Medicaid
NCNCU755AMedicare PIN