MEDICARE: YAROSLAV A GOFNUNG MD

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740224021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YAROSLAV A GOFNUNG MD

Provider Business Mailing Address
First Line	:	5805 SEPULVEDA BLVD
Second Line	:	SUITE 610
City	:	VAN NUYS
State	:	CA
Zip	:	91411-2546
Country	:	US
Telephone Number	:	818-908-8048
Fax Number	:	818-908-8072

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	09/21/2012

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Practice Fax: 818-487-0050

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