Provider Demographics
NPI:1104322205
Name:GARY, CYRIL SERGEI (MD)
Entity type:Individual
Prefix:
First Name:CYRIL
Middle Name:SERGEI
Last Name:GARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CYIL
Other - Middle Name:
Other - Last Name:KOUZNETSOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL PLAZA SUITE 170
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PLAZA SUITE 170
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-2113
Practice Address - Country:US
Practice Address - Phone:310-319-1234
Practice Address - Fax:202-444-7204
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1949351835P0018X, 207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program