Healthcare Provider Details

I. General information

NPI: 1104322205
Provider Name (Legal Business Name): CYRIL SERGEI GARY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CYIL KOUZNETSOV

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3617 AVALON BLVD STE 200
LOS ANGELES CA
90011-5601
US

IV. Provider business mailing address

3617 AVALON BLVD STE 200
LOS ANGELES CA
90011-5601
US

V. Phone/Fax

Practice location:
  • Phone: 213-935-8577
  • Fax:
Mailing address:
  • Phone: 213-935-8577
  • Fax: 213-935-8576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberA194935
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA194935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: