Provider Demographics
NPI:1144732595
Name:EBTISSAM H KORKIS MD INC
Entity type:Organization
Organization Name:EBTISSAM H KORKIS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICAL/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EBTISSAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:KORKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-441-9200
Mailing Address - Street 1:1530 JAMACHA RD STE E-F
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-3700
Mailing Address - Country:US
Mailing Address - Phone:619-441-9200
Mailing Address - Fax:619-441-0710
Practice Address - Street 1:1530 JAMACHA RD STE E-F
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-3700
Practice Address - Country:US
Practice Address - Phone:619-441-9200
Practice Address - Fax:619-441-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A897670Medicaid