Provider Demographics
NPI:1932471125
Name:RICHARD L.KORNBERG, M.D.A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD L.KORNBERG, M.D.A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:KORNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-459-8874
Mailing Address - Street 1:110 W PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4016
Mailing Address - Country:US
Mailing Address - Phone:619-298-7546
Mailing Address - Fax:619-692-1397
Practice Address - Street 1:110 W 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13900302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization