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: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLAZA SUITE 170
LOS ANGELES CA
90095-2113
US

IV. Provider business mailing address

100 MEDICAL PLAZA SUITE 170
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-319-1234
  • Fax: 202-444-7204
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberA194935
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA194935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: