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
StateLicense IDTaxonomies
CAG139000207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G139000Medicaid
CAG139000Medicare ID - Type Unspecified
CA00G139000Medicaid