Basic Information
| Provider Information | |||||||||
| NPI: | 1114361029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUVOROVA | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | VYACHESLAVOVNA | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 F ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919102632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194273481 | ||||||||
| FaxNumber: | 6194207807 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 F ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919102632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194273481 | ||||||||
| FaxNumber: | 6194207807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 5305 | CA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.