Provider Demographics
NPI:1780746263
Name:KORKIS, EBTISSAM H (MD)
Entity type:Individual
Prefix:
First Name:EBTISSAM
Middle Name:H
Last Name:KORKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EBTISAM
Other - Middle Name:H
Other - Last Name:GEORGES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1530 JAMACHA ROAD
Mailing Address - Street 2:UNIT E
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019
Mailing Address - Country:US
Mailing Address - Phone:619-441-9200
Mailing Address - Fax:
Practice Address - Street 1:1530 JAMACHA ROAD
Practice Address - Street 2:UNIT E UNIT F
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019
Practice Address - Country:US
Practice Address - Phone:619-441-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A897670Medicaid
168002Medicare UPIN
CA00A897670Medicaid
A89767Medicare PIN