Provider Demographics
NPI:1619085339
Name:GONCHAROVA, ELENA L (MD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:L
Last Name:GONCHAROVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 5350 S
Mailing Address - Street 2:STE 335
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6946
Mailing Address - Country:US
Mailing Address - Phone:801-475-5100
Mailing Address - Fax:801-475-8580
Practice Address - Street 1:425 E 5350 S
Practice Address - Street 2:STE 335
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6946
Practice Address - Country:US
Practice Address - Phone:801-475-5100
Practice Address - Fax:801-475-8580
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5378651-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT649502110001Medicaid
UT649502110001Medicaid
UT005752301Medicare ID - Type Unspecified