Healthcare Provider Details

I. General information

NPI: 1952496291
Provider Name (Legal Business Name): OLEG M GAVRILYUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD STE. 2302
SAN DIEGO CA
92120-5244
US

IV. Provider business mailing address

6699 ALVARADO RD STE 2302
SAN DIEGO CA
92120-5241
US

V. Phone/Fax

Practice location:
  • Phone: 619-578-2518
  • Fax: 619-501-6498
Mailing address:
  • Phone: 619-578-2518
  • Fax: 619-501-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA74418
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number74418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: