Provider Demographics
NPI:1184844573
Name:KORNBAU, JAMES ROBERT (MS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:KORNBAU
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56515 LEVI BUNCH RD
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-7742
Mailing Address - Country:US
Mailing Address - Phone:541-396-3467
Mailing Address - Fax:541-266-9763
Practice Address - Street 1:160 S 2ND ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1603
Practice Address - Country:US
Practice Address - Phone:541-266-9639
Practice Address - Fax:541-266-9763
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21488231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR126354Medicaid
OR126354Medicaid