NPIMap

Organization Active NPI

Calixto J Cornavaca Diaz MD LLC

Doing business as Cornavaca Clinic

  • General Practice Physician
  • Gainesville, GA
National Provider Identifier
1487140349
Registry record updated Jul 3, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
License
74951 Issued in GA
Legal business name
CALIXTO J CORNAVACA DIAZ MD LLC
Doing business as
Cornavaca Clinic
Practice address
578 S Enota Dr NE Ste C
Gainesville, GA 30501-8947
Phone
(470) 892-6607
Fax
(470) 290-8474
NPI assigned
Jul 3, 2018
Last updated
Jul 3, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 3, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Spring Cornavaca
Title
Business Administrator
Phone
(470) 892-6607

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 028490 GA
General Practice Physician 208D00000X 74951 GA Primary

Addresses

Primary practice location

578 S Enota Dr NE Ste C
Gainesville, GA 30501-8947

Mailing address

578 S Enota Dr NE Ste C
Gainesville, GA 30501-8947
Phone (470) 892-6607

Other identifiers 2

IdentifierTypeStateIssuer
1417990334MedicaidGA
1326381625MedicaidTN

Other names 1

  • Cornavaca Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20181120000757 GA Part B Supplier - Clinic/Group Practice 2961756432 Receives reassigned benefits from 2 practitioners
Practice locations: Gainesville, GA

National Provider Directory

National Provider Directory

Locations

578 S Enota Dr NE
#C
Gainesville, GA 30501

578 S Enota Dr NE
Ste C
Gainesville, GA 30501
Phone (470) 290-8474

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1530576000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1530576000000",
    "number": "1487140349",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "578 S ENOTA DR NE STE C",
            "city": "GAINESVILLE",
            "state": "GA",
            "postal_code": "305018947",
            "telephone_number": "470-892-6607",
            "fax_number": "470-290-8474"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "578 S ENOTA DR NE STE C",
            "city": "GAINESVILLE",
            "state": "GA",
            "postal_code": "305018947",
            "telephone_number": "470-892-6607",
            "fax_number": "470-290-8474"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CALIXTO J CORNAVACA DIAZ MD LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-03",
        "last_updated": "2018-07-03",
        "status": "A",
        "authorized_official_last_name": "CORNAVACA",
        "authorized_official_first_name": "SPRING",
        "authorized_official_title_or_position": "BUSINESS ADMINISTRATOR",
        "authorized_official_telephone_number": "470-892-6607",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": "028490",
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "GA",
            "license": "74951",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1417990334",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1326381625",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cornavaca Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gainesville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.