=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780680140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD R ETZKORN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2005
-----------------------------------------------------
Last Update Date | 11/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19066 MAGNOLIA ST.
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-968-0068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19066 MAGNOLIA ST
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92646-2232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-968-0068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G57149
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | G57149
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------