Provider Demographics
NPI:1144777590
Name:OLEG M. GAVRILYUK, M.D., PC
Entity Type:Organization
Organization Name:OLEG M. GAVRILYUK, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAVRILYUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-764-0330
Mailing Address - Street 1:6699 ALVARADO RD
Mailing Address - Street 2:#2302
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:#2302
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5244
Practice Address - Country:US
Practice Address - Phone:619-764-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty