Provider Demographics
NPI:1386968543
Name:SERGE OBUKHOV, M.D. PC
Entity type:Organization
Organization Name:SERGE OBUKHOV, M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBUKHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-740-1778
Mailing Address - Street 1:27159 SEA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4436
Mailing Address - Country:US
Mailing Address - Phone:714-740-1778
Mailing Address - Fax:714-740-1913
Practice Address - Street 1:13252 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2204
Practice Address - Country:US
Practice Address - Phone:714-740-1778
Practice Address - Fax:714-740-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65490207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH38580Medicare UPIN