Provider Demographics
NPI:1154438935
Name:STORKERSEN, KRIS JOHN (MD)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:JOHN
Last Name:STORKERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:909-747-0371
Mailing Address - Fax:909-307-3287
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:ARMC MODULAR# 3
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6210
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG69270207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
CAGR0079700Medicaid
CA00G692700Medicare PIN
F63182Medicare UPIN