Provider Demographics
NPI:1053872309
Name:KORSUN, PHILIP EFRAIM (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:EFRAIM
Last Name:KORSUN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4307 FREEDOM DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-5129
Mailing Address - Country:US
Mailing Address - Phone:323-610-8965
Mailing Address - Fax:
Practice Address - Street 1:14850 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4677
Practice Address - Country:US
Practice Address - Phone:818-787-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A19382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD8812052Medicaid