Provider Demographics
NPI:1699161885
Name:JOEL BARRY KORNBERG, MD, PA
Entity type:Organization
Organization Name:JOEL BARRY KORNBERG, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:KORNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-531-9775
Mailing Address - Street 1:7777 GLADES RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4194
Mailing Address - Country:US
Mailing Address - Phone:954-531-9775
Mailing Address - Fax:
Practice Address - Street 1:7777 GLADES RD
Practice Address - Street 2:STE 100
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-4194
Practice Address - Country:US
Practice Address - Phone:954-531-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39029208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D27975Medicare UPIN