MEDICARE: DR. EDWARD R ETZKORN 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	207R00000X	Internal Medicine Physician	G57149	CA
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	G57149	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G571490	OTHER	CA	MEDI CAL #

General Provider Information

NPI Number	:	1780680140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD R ETZKORN MD

Provider Business Mailing Address
First Line	:	19066 MAGNOLIA ST
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92646-2232
Country	:	US
Telephone Number	:	714-968-0068
Fax Number	:

Provider Business Practice Location Address
First Line	:	19066 MAGNOLIA ST.
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92646
Country	:	US
Telephone Number	:	714-968-0068
Fax Number	:

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	11/05/2012

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