Healthcare Provider Details

I. General information

NPI: 1710943451
Provider Name (Legal Business Name): PAUL B KORNBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2914 N BOULEVARD
TAMPA FL
33602-1208
US

IV. Provider business mailing address

2914 N BOULEVARD
TAMPA FL
33602-1208
US

V. Phone/Fax

Practice location:
  • Phone: 813-228-7696
  • Fax: 813-228-0677
Mailing address:
  • Phone: 813-228-7696
  • Fax: 813-228-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME0085060
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberME0085060
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: