Provider Demographics
NPI:1245288240
Name:KORNBLUTH, RICHARD SYD (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SYD
Last Name:KORNBLUTH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 LA JOLLA BLVD STE 76
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7651
Mailing Address - Country:US
Mailing Address - Phone:619-846-8603
Mailing Address - Fax:858-456-7436
Practice Address - Street 1:3030 BUNKER HILL ST STE 115B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109
Practice Address - Country:US
Practice Address - Phone:619-846-8603
Practice Address - Fax:858-456-7436
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51776207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G517760Medicaid
CAWG51776BMedicare ID - Type Unspecified
CA00G517760Medicaid