MEDICARE: RICHARD L.KORNBERG, M.D.A PROFESSIONAL CORPORATION

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	302F00000X	Exclusive Provider Organization	G13900	CA

General Provider Information

NPI Number	:	1932471125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD L.KORNBERG, M.D.A PROFESSIONAL CORPORATION

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

Provider Business Practice Location Address
First Line	:	110 W 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	:	SECRETARY/TREASURER
Name	:	MRS. EDITH L KORNBERG
Credential	:
Telephone Number	:	858-459-8874

Provider Enumeration Date	:	02/02/2012
Last Update Date	:	02/02/2012

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