Provider Demographics
NPI:1104824101
Name:GOUFMAN, DIMITRY B (MD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRY
Middle Name:B
Last Name:GOUFMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:302 WEST LAVETA AVE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866
Mailing Address - Country:US
Mailing Address - Phone:714-835-4404
Mailing Address - Fax:714-532-6563
Practice Address - Street 1:302 WEST LAVETA AVE.
Practice Address - Street 2:SUITE 201
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866
Practice Address - Country:US
Practice Address - Phone:714-835-4404
Practice Address - Fax:714-532-6563
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52758207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21748Medicare PIN