Provider Demographics
NPI:1871522664
Name:HORNBECK, LAMONT WALLACE (MD)
Entity type:Individual
Prefix:
First Name:LAMONT
Middle Name:WALLACE
Last Name:HORNBECK
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 1:729 SUNRISE AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4565
Mailing Address - Country:US
Mailing Address - Phone:916-782-3721
Mailing Address - Fax:916-782-0618
Practice Address - Street 1:729 SUNRISE AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4565
Practice Address - Country:US
Practice Address - Phone:916-782-3721
Practice Address - Fax:916-782-0618
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0517340207N00000X, 207NI0002X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G517340Medicaid
CAA 89936Medicare UPIN
CA00G517340Medicare ID - Type Unspecified