Healthcare Provider Details

I. General information

NPI: 1104912336
Provider Name (Legal Business Name): DAVID KOROSHEC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 BEVERLY BLVD
LOS ANGELES CA
90057-2402
US

IV. Provider business mailing address

1766 LAS LUNAS ST
PASADENA CA
91106-1305
US

V. Phone/Fax

Practice location:
  • Phone: 213-353-1140
  • Fax: 213-607-1434
Mailing address:
  • Phone: 213-353-1140
  • Fax: 213-607-1434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG49623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: