Provider Demographics
NPI: | 1558456947 |
---|---|
Name: | KORNBERG, RICHARD LLOYD (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | RICHARD |
Middle Name: | LLOYD |
Last Name: | KORNBERG |
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: | 1821 CASTELLANA RD |
Mailing Address - Street 2: | |
Mailing Address - City: | LA JOLLA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92037-3841 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 858-459-8874 |
Mailing Address - Fax: | 858-459-8884 |
Practice Address - Street 1: | 110 WEST PENNSYLVANIA AVE |
Practice Address - Street 2: | |
Practice Address - City: | SAN DIEGO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92103-4016 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-298-7546 |
Practice Address - Fax: | 619-692-1397 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-03 |
Last Update Date: | 2011-10-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G139000 | 207N00000X, 207ND0900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ND0900X | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00G139000 | Medicaid | |
CA | G139000 | Medicare ID - Type Unspecified | |
CA | 00G139000 | Medicaid |