Provider Demographics
NPI:1376747394
Name:WALLACE M KORBIN MD A MEDICAL CORP
Entity Type:Organization
Organization Name:WALLACE M KORBIN MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KORBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-988-0170
Mailing Address - Street 1:PO BOX 492267
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:818-988-0170
Mailing Address - Fax:818-367-0767
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:SUITE #209
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-988-0170
Practice Address - Fax:818-367-0767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC18692207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC18692AOtherSTATE OF CALIFORNIA
CAC18692AOtherSTATE OF CALIFORNIA