MEDICARE: OLGA GOULKO M.D.

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	207N00000X	Dermatology Physician	MA065361	NJ

General Provider Information

NPI Number	:	1710094578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLGA GOULKO M.D.

Provider Business Mailing Address
First Line	:	2125 CENTER AVE STE 200
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5810
Country	:	US
Telephone Number	:	201-461-5655
Fax Number	:	201-461-1181

Provider Business Practice Location Address
First Line	:	2125 CENTER AVE STE 200
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5810
Country	:	US
Telephone Number	:	201-461-5655
Fax Number	:	201-461-1181

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/08/2007

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