Provider Demographics
NPI:1982732277
Name:GAVRILYUK, IGOR (MD)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:GAVRILYUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 FOURTH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2120
Mailing Address - Country:US
Mailing Address - Phone:619-718-9444
Mailing Address - Fax:619-718-9440
Practice Address - Street 1:4060 FOURTH AVE SUITE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-718-9444
Practice Address - Fax:619-718-9440
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine