Provider Demographics
NPI:1538333497
Name:LAVISTA FAMILY MEDICINE
Entity Type:Organization
Organization Name:LAVISTA FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOROKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-320-6050
Mailing Address - Street 1:2012 HAROBI DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5161
Mailing Address - Country:US
Mailing Address - Phone:404-320-6050
Mailing Address - Fax:404-320-6080
Practice Address - Street 1:2910 N DRUID HILLS RD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3919
Practice Address - Country:US
Practice Address - Phone:404-320-6050
Practice Address - Fax:404-320-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039353261QP2300X
GA042048261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000662219EMedicaid
GA000662219EMedicaid
GAGRP4906Medicare PIN