Healthcare Provider Details

I. General information

NPI: 1245288240
Provider Name (Legal Business Name): RICHARD SYD KORNBLUTH M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 BUNKER HILL ST STE 115B
SAN DIEGO CA
92109
US

IV. Provider business mailing address

5580 LA JOLLA BLVD STE 76
LA JOLLA CA
92037-7651
US

V. Phone/Fax

Practice location:
  • Phone: 619-846-8603
  • Fax: 858-456-7436
Mailing address:
  • Phone: 619-846-8603
  • Fax: 858-456-7436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG51776
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG51776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: