MEDICARE: YAROSLAV A. GOFNUNG, M.D., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	A81752	CA

General Provider Information

NPI Number	:	1013024876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YAROSLAV A. GOFNUNG, M.D., INC.

Provider Business Mailing Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	SUITE 225
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3429
Country	:	US
Telephone Number	:	818-487-0040
Fax Number	:	818-487-0050

Provider Business Practice Location Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	SUITE 225
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3429
Country	:	US
Telephone Number	:	818-487-0040
Fax Number	:	818-487-0050

Authorized Official
Title or Position	:	BILLING/CREDENTIALING
Name	:	PAULA MARTINEZ
Credential	:
Telephone Number	:	818-908-8048

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	06/21/2018

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Practice Location Address:

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Practice Phone: 818-487-0040
Practice Fax: 818-487-0050

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