Provider Demographics
NPI:1104912336
Name:KOROSHEC, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:KOROSHEC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1766 LAS LUNAS ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1305
Mailing Address - Country:US
Mailing Address - Phone:213-353-1140
Mailing Address - Fax:213-607-1434
Practice Address - Street 1:1926 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2402
Practice Address - Country:US
Practice Address - Phone:213-353-1140
Practice Address - Fax:213-607-1434
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49623207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G496230Medicaid
CAC96242Medicare UPIN
CA00G496230Medicaid