Provider Demographics
NPI:1821089269
Name:HORNICKLE, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HORNICKLE
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 1:346 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19547-8712
Mailing Address - Country:US
Mailing Address - Phone:610-987-9870
Mailing Address - Fax:610-987-0029
Practice Address - Street 1:346 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEY
Practice Address - State:PA
Practice Address - Zip Code:19547-8712
Practice Address - Country:US
Practice Address - Phone:610-987-9870
Practice Address - Fax:610-987-0029
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100901959Medicaid
PA100901959Medicaid
PAMT04931Medicare UPIN