Basic Information
| Provider Information | |||||||||
| NPI: | 1467411918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVRILOVA | ||||||||
| FirstName: | SVETLANA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8900 VAN WYCK EXPY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182067820 | ||||||||
| FaxNumber: | 7182066786 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 VAN WYCK EXPY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182066894 | ||||||||
| FaxNumber: | 7186570545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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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 | 208100000X | 218421 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 02183746 | 05 | NY | MEDICAID |