Healthcare Provider Details

I. General information

NPI: 1164839700
Provider Name (Legal Business Name): OFELYA GEVORGYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4234
US

IV. Provider business mailing address

1650 W HARRISON ST STE 466
CHICAGO IL
60612-3800
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD60954239
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number036.141330
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: