=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215976154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELVIN HORNBUCKLE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2006
-----------------------------------------------------
Last Update Date | 08/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 885 KEMPSVILLE RD SUITE 114
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-466-0165
-----------------------------------------------------
Fax | 757-466-7296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 885 KEMPSVILLE RD SUITE 114
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-466-0165
-----------------------------------------------------
Fax | 757-466-7296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 0101230915
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------