Provider Demographics
NPI:1336900968
Name:GOLUBJATNIKOV, OLAF KRISTIAN
Entity type:Individual
Prefix:
First Name:OLAF
Middle Name:KRISTIAN
Last Name:GOLUBJATNIKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KALEV
Other - Middle Name:
Other - Last Name:GOLUBJATNIKOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:65 MILLARD RD
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1957
Mailing Address - Country:US
Mailing Address - Phone:415-306-3743
Mailing Address - Fax:
Practice Address - Street 1:46900 OCEAN VIEW DR
Practice Address - Street 2:
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445-8458
Practice Address - Country:US
Practice Address - Phone:707-884-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95026352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine