Provider Demographics
NPI:1821299298
Name:JACOB KORULA, M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JACOB KORULA, M.D. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:KORULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-447-5339
Mailing Address - Street 1:622 W DUARTE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-9278
Mailing Address - Country:US
Mailing Address - Phone:626-447-5339
Mailing Address - Fax:
Practice Address - Street 1:622 W DUARTE ROAD
Practice Address - Street 2:SUITE 302
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9278
Practice Address - Country:US
Practice Address - Phone:626-447-5339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2009-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39567207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28910Medicare UPIN