=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790846657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DINA SVERDLOV MD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 10/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S ELLSWORTH AVE STE 208
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-343-8512
-----------------------------------------------------
Fax | 650-343-8412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BAYWOOD AVE STE 4
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94402-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-343-8512
-----------------------------------------------------
Fax | 650-343-8412
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DINA SVERDLOV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 650-343-8512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A70283
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------