Active NPI
Michael Kornberg, M.D.
- Child & Adolescent Psychiatry Physician
- San Diego, CA
National Provider Identifier
1174786834
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Child & Adolescent Psychiatry Physician
- License
- A101909
- Practice address
- 12625 High Bluff Dr
Suite 305
San Diego, CA 92130-2052 - Phone
- (858) 279-1223
- Fax
- (858) 509-4789
- NPI assigned
- Jul 3, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Child & Adolescent Psychiatry Physician | 2084P0804X | A101909 | CA | Primary |
Addresses
Primary practice location
12625 High Bluff Dr
Suite 305
San Diego, CA 92130-2052
Mailing address
12625 High Bluff Dr
Suite 305
San Diego, CA 92130-2052
Phone (858) 279-1223
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 95-1691313 | Other | CA | RADY CHILDREN'S HOSPITAL SAN DIEGO, OUTPATIENT PSYCHIATRY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Feb 10, 2022 through Feb 10, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| A101909 | CA | MD | Child & Adolescent Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1215043200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1276646400000",
"number": "1174786834",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12625 HIGH BLUFF DR",
"address_2": "SUITE 305",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921302052",
"telephone_number": "858-279-1223",
"fax_number": "858-509-4789"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12625 HIGH BLUFF DR",
"address_2": "SUITE 305",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921302052",
"telephone_number": "858-279-1223",
"fax_number": "858-509-4789"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KORNBERG",
"first_name": "MICHAEL",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-07-03",
"last_updated": "2010-06-16",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0804X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
"state": "CA",
"license": "A101909",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RADY CHILDREN'S HOSPITAL SAN DIEGO, OUTPATIENT PSYCHIATRY",
"identifier": "95-1691313",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.