Provider Demographics
NPI:1629098116
Name:BORODULIN-SMIK, IRINA (DC)
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:BORODULIN-SMIK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EMBARCADERO CTR STE 19002ND
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3628
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:803 ELEVENTH AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94089-4731
Practice Address - Country:US
Practice Address - Phone:408-228-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 27390111N00000X
CAPA22970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64417Z-30OtherBLUE SHIELD OF CALIFORNIA
CADC0273900Medicaid
CADC0273900Medicaid
CADC0273900Medicaid
CAU91087Medicare UPIN