=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538333497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAVISTA FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2008
-----------------------------------------------------
Last Update Date | 10/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2910 N DRUID HILLS RD NE SUITE A
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-320-6050
-----------------------------------------------------
Fax | 404-320-6080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2012 HAROBI DR SUITE B
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-5161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-320-6050
-----------------------------------------------------
Fax | 404-320-6080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY PRACTICE
-----------------------------------------------------
Name | DR. MIKHAIL GOROKHOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-320-6050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 042048
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 039353
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------