Provider Demographics
NPI:1366434268
Name:HORNBECK, KEVIN L (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:HORNBECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7102
Mailing Address - Country:US
Mailing Address - Phone:419-251-2032
Mailing Address - Fax:419-251-1485
Practice Address - Street 1:730 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-226-4310
Practice Address - Fax:419-226-4315
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2018-05-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OH34005321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0420471OtherUHC
000000077070OtherANTHEM
OH0869074Medicaid
F55975Medicare UPIN
OH4013541Medicare PIN