MEDICARE: OLEG M GAVRILYUK M.D.

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	174400000X	Specialist	A74418	CA
2	208100000X	Physical Medicine & Rehabilitation Physician	74418	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A74418	OTHER	CA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1952496291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLEG M GAVRILYUK M.D.

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD
Second Line	:	STE 2302
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5241
Country	:	US
Telephone Number	:	619-578-2518
Fax Number	:	619-501-6498

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD
Second Line	:	STE. 2302
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5244
Country	:	US
Telephone Number	:	619-578-2518
Fax Number	:	619-501-6498

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	11/17/2016

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