Provider Demographics
NPI:1790846657
Name:DINA SVERDLOV MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DINA SVERDLOV MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SVERDLOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-343-8512
Mailing Address - Street 1:1 BAYWOOD AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1537
Mailing Address - Country:US
Mailing Address - Phone:650-343-8512
Mailing Address - Fax:650-343-8412
Practice Address - Street 1:100 S ELLSWORTH AVE STE 208
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3932
Practice Address - Country:US
Practice Address - Phone:650-343-8512
Practice Address - Fax:650-343-8412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0974111OtherCLIA SAN MATEO
CA00A702831Medicaid
CA00A702830Medicaid
CA05D0971734OtherCLIA SAN FRANCISCO
CA00A702830Medicaid
CAG88087Medicare UPIN
CA05D0974111OtherCLIA SAN MATEO