Provider Demographics
NPI:1437109683
Name:SOROKA, EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:SOROKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YEVGENIY
Other - Middle Name:
Other - Last Name:SHAPOVALOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4611 VISTA DEL MONTE AVE
Mailing Address - Street 2:UNIT 204
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2944
Mailing Address - Country:US
Mailing Address - Phone:818-674-7838
Mailing Address - Fax:805-247-0508
Practice Address - Street 1:246 E SCOTT STREET
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2918
Practice Address - Country:US
Practice Address - Phone:805-247-0708
Practice Address - Fax:805-247-0508
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A923490Medicaid
CAWA92349AMedicare PIN