Provider Demographics
NPI:1013024876
Name:YAROSLAV A. GOFNUNG, M.D., INC.
Entity Type:Organization
Organization Name:YAROSLAV A. GOFNUNG, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-908-8048
Mailing Address - Street 1:12660 RIVERSIDE DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3429
Mailing Address - Country:US
Mailing Address - Phone:818-487-0040
Mailing Address - Fax:818-487-0050
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:SUITE 225
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-487-0040
Practice Address - Fax:818-487-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81752207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID