Provider Demographics
NPI:1114361029
Name:SOUVOROVA, JULIA VYACHESLAVOVNA (DPM)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:VYACHESLAVOVNA
Last Name:SOUVOROVA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 F ST
Mailing Address - Street 2:STE 100
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2632
Mailing Address - Country:US
Mailing Address - Phone:619-427-3481
Mailing Address - Fax:619-420-7807
Practice Address - Street 1:345 F ST
Practice Address - Street 2:STE 100
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2632
Practice Address - Country:US
Practice Address - Phone:619-427-3481
Practice Address - Fax:619-420-7807
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5305213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB263408Medicare PIN