Provider Demographics
NPI:1740224021
Name:GOFNUNG, YAROSLAV A (MD)
Entity Type:Individual
Prefix:
First Name:YAROSLAV
Middle Name:A
Last Name:GOFNUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5805 SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2546
Mailing Address - Country:US
Mailing Address - Phone:818-908-8048
Mailing Address - Fax:818-908-8072
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:SUITE 225
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-487-0040
Practice Address - Fax:818-487-0050
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2012-09-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA81752207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740224021Medicaid
CAI57780Medicare UPIN
CA1740224021Medicaid
CAGC480ZMedicare PIN