Provider Demographics
NPI:1770584906
Name:HORNBAKE, EARL RODNEY III (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:RODNEY
Last Name:HORNBAKE
Suffix:III
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 1:10 WILDWOOD MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1154
Mailing Address - Country:US
Mailing Address - Phone:860-767-0145
Mailing Address - Fax:860-767-0021
Practice Address - Street 1:10 WILDWOOD MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1154
Practice Address - Country:US
Practice Address - Phone:860-767-0145
Practice Address - Fax:860-767-0021
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034326207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03139OtherMEDICARE GROUP NUMBER
CT034326OtherLICENSE
CT001343269Medicaid
C87498Medicare UPIN
11000925Medicare ID - Type Unspecified