Healthcare Provider Details

I. General information

NPI: 1487839635
Provider Name (Legal Business Name): IDL MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8767 BOYNTON BEACH BLVD
BOYNTON BEACH FL
33472-4479
US

IV. Provider business mailing address

8767 BOYNTON BEACH BLVD
BOYNTON BEACH FL
33472-4479
US

V. Phone/Fax

Practice location:
  • Phone: 561-734-5484
  • Fax: 561-734-5485
Mailing address:
  • Phone: 561-734-5484
  • Fax: 561-734-5485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANA GOROKHOVKSY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 305-725-5529