Provider Demographics
NPI:1518151687
Name:PUSHKAREVA, TATYANA
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:PUSHKAREVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81735 HWY 111#A
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3462
Mailing Address - Country:US
Mailing Address - Phone:760-391-4466
Mailing Address - Fax:760-342-1823
Practice Address - Street 1:81735 HWY 111 #A
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3462
Practice Address - Country:US
Practice Address - Phone:760-391-4466
Practice Address - Fax:760-342-1823
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD56088Medicaid