Provider Demographics
NPI:1508870171
Name:KORMAN, JEREMY E (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:E
Last Name:KORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4644 LINCOLN BLVD
Mailing Address - Street 2:STE 450
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6313
Mailing Address - Country:US
Mailing Address - Phone:310-577-5540
Mailing Address - Fax:310-577-5616
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:STE 450
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:800-491-1977
Practice Address - Fax:310-577-5616
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-09-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG83221208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46936Medicare UPIN