Provider Demographics
NPI:1609857028
Name:CORNELL, DAN ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:ROGER
Last Name:CORNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 OCEAN DR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2110
Mailing Address - Country:US
Mailing Address - Phone:301-455-1090
Mailing Address - Fax:
Practice Address - Street 1:1500 5TH AVE
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-2422
Practice Address - Country:US
Practice Address - Phone:412-664-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00395182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147891500Medicaid
MD005L218AMedicare ID - Type Unspecified