Provider Demographics
NPI:1124158191
Name:SIRBILADZE, YELENA (MD)
Entity type:Individual
Prefix:DR
First Name:YELENA
Middle Name:
Last Name:SIRBILADZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 ENBORG LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2608
Mailing Address - Country:US
Mailing Address - Phone:408-885-6220
Mailing Address - Fax:
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA761432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91891ZOtherSANTA CRUZ COUNTY CA MEDICARE GROUP PTAN#
CAFHC 70044FOtherSANTA CRUZ COUNTY CA MEDI-CAL GROUP PTAN
CAFHC 70042FOtherSANTA CRUZ COUNTY CA MEDI-CAL GROUP PTAN
CAZZZ91892ZOtherSANTA CRUZ COUNTY CA MEDICARE GROUP PTAN#
CAZZZ92069ZOtherSANTA CRUZ COUNTY CA MEDICARE GROUP PTAN#
CAZZZ91891ZOtherSANTA CRUZ COUNTY CA MEDICARE GROUP PTAN#