Provider Demographics
NPI:1265673263
Name:HORNBAKER-PARK, MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HORNBAKER-PARK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HORNBAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:109 W 27TH ST RM 5S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6208
Mailing Address - Country:US
Mailing Address - Phone:833-351-8255
Mailing Address - Fax:
Practice Address - Street 1:66 E MAIN ST
Practice Address - Street 2:2ND AND 3RD FLOOR (PRIVATE OFFICE 303)
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157
Practice Address - Country:US
Practice Address - Phone:833-351-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29351152084P0800X
DCMD5000023182084P0800X
TN552372084P0804X
VA01012798812084P0804X
MDD00953922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN