Provider Demographics
NPI:1891971404
Name:ERROL KORN MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ERROL KORN MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-425-5544
Mailing Address - Street 1:1044 PACIFIC HILL ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6831
Mailing Address - Country:US
Mailing Address - Phone:619-425-5544
Mailing Address - Fax:619-421-3838
Practice Address - Street 1:769 MEDICAL CENTER CT # 303
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6602
Practice Address - Country:US
Practice Address - Phone:619-425-5544
Practice Address - Fax:619-421-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG154810207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G154810Medicaid
CAA90388Medicare UPIN
CAFU495AMedicare PIN