Provider Demographics
NPI:1780680140
Name:ETZKORN, EDWARD R (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:R
Last Name:ETZKORN
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 1:19066 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-2232
Mailing Address - Country:US
Mailing Address - Phone:714-968-0068
Mailing Address - Fax:
Practice Address - Street 1:19066 MAGNOLIA ST.
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646
Practice Address - Country:US
Practice Address - Phone:714-968-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57149207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G571490OtherMEDI CAL #
CA00G571490OtherMEDI CAL #