Provider Demographics
NPI:1790770964
Name:HORNBACK, DAVID ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:HORNBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1063
Practice Address - Country:US
Practice Address - Phone:574-647-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010376072085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200001760Medicaid
IN200001760Medicaid
INP00353700OtherMEDICARE RAILROAD
INP00765218OtherRR MEDICARE
IN000000595756OtherBCBS BMG ONCOLOGY
MI104944880Medicaid
MI104945968Medicaid
OH2696971Medicaid
MI104944880Medicaid
INP00765218OtherRR MEDICARE
INP00353700OtherMEDICARE RAILROAD
E48285Medicare UPIN