Provider Demographics
NPI:1386888659
Name:GAVRILOVA, TATYANA (MD)
Entity type:Individual
Prefix:MISS
First Name:TATYANA
Middle Name:
Last Name:GAVRILOVA
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 1:111 EAST 210TH STREET
Mailing Address - Street 2:MONTEFIORE MEDICAL CENTER
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467
Mailing Address - Country:US
Mailing Address - Phone:718-405-8530
Mailing Address - Fax:
Practice Address - Street 1:111 EAST 210TH STREET
Practice Address - Street 2:MONTEFIORE MEDICAL CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-405-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY266400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program