Provider Demographics
NPI:1467459883
Name:KORNBERG, ELLIOT HAROLD (MD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:HAROLD
Last Name:KORNBERG
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 1:650 N ATLANTIC AVE
Mailing Address - Street 2:PENTHOUSE 5
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3119
Mailing Address - Country:US
Mailing Address - Phone:321-783-7079
Mailing Address - Fax:321-783-5228
Practice Address - Street 1:1980 N ATLANTIC AVE
Practice Address - Street 2:SUITE 416
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5213
Practice Address - Country:US
Practice Address - Phone:321-783-7079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0025763208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78269Medicare ID - Type Unspecified
FLD77533Medicare UPIN