Provider Demographics
NPI:1295732568
Name:KORULA, JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:KORULA
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 1:622 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:626-447-5353
Practice Address - Street 1:622 W DUARTE RD
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:626-447-5353
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39567207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A395670Medicaid
CA00A395670Medicaid
CAA39567Medicare ID - Type UnspecifiedPROVIDER NUMBER