Basic Information
| Provider Information | |||||||||
| NPI: | 1518166073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORBACHOVA | ||||||||
| FirstName: | TETYANA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9330 JAMISON AVE | ||||||||
| Address2: | UNIT B | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191154277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2672515631 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | 114 - BONEPIT | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586423343 | ||||||||
| FaxNumber: | 8585527565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2007 | ||||||||
| LastUpdateDate: | 07/15/2007 | ||||||||
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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 | 2085R0202X | A94657 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.