Provider Demographics
NPI:1063742856
Name:KORNBERG, MICHAEL DAVIN (MD, PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVIN
Last Name:KORNBERG
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N. WOLFE STREET
Mailing Address - Street 2:PATHOLOGY 627
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287
Mailing Address - Country:US
Mailing Address - Phone:410-614-1096
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:ZAYED 6005
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:410-955-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00789312084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty