Healthcare Provider Details

I. General information

NPI: 1235308818
Provider Name (Legal Business Name): YELENA LAPIDUS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 03/02/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6685 BAY LAUREL PLACE
AVILA BEACH CA
93424
US

IV. Provider business mailing address

PO BOX 490
AVILA BEACH CA
93424-0490
US

V. Phone/Fax

Practice location:
  • Phone: 805-540-3071
  • Fax: 805-540-3072
Mailing address:
  • Phone: 805-540-3071
  • Fax: 805-540-3072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA88176
License Number StateCA

VIII. Authorized Official

Name: KEIRA GREGORY
Title or Position: BILLING/CREDENTIALING ADMINISTRATOR
Credential:
Phone: 317-332-1189