Provider Demographics
NPI:1952496291
Name:GAVRILYUK, OLEG M (MD)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:M
Last Name:GAVRILYUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6699 ALVARADO RD
Mailing Address - Street 2:STE 2302
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5241
Mailing Address - Country:US
Mailing Address - Phone:619-578-2518
Mailing Address - Fax:619-501-6498
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:STE. 2302
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5244
Practice Address - Country:US
Practice Address - Phone:619-578-2518
Practice Address - Fax:619-501-6498
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74418174400000X
CA74418208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA74418OtherMEDICAL LICENSE
CA00A744180Medicaid
CAH48463Medicare UPIN