MEDICARE: RICHARD LLOYD KORNBERG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	G139000	CA
2	207ND0900X	Dermatopathology Physician	G139000	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558456947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD LLOYD KORNBERG MD

Provider Business Mailing Address
First Line	:	1821 CASTELLANA RD
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-3841
Country	:	US
Telephone Number	:	858-459-8874
Fax Number	:	858-459-8884

Provider Business Practice Location Address
First Line	:	110 WEST PENNSYLVANIA AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4016
Country	:	US
Telephone Number	:	619-298-7546
Fax Number	:	619-692-1397

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	10/05/2011

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