Provider Demographics
NPI:1043679673
Name:GUTKOVSKY, BORIS (CPT1)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:GUTKOVSKY
Suffix:
Gender:M
Credentials:CPT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CHUMASERO DR APT 2D
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-2319
Mailing Address - Country:US
Mailing Address - Phone:415-867-2235
Mailing Address - Fax:
Practice Address - Street 1:55 CHUMASERO DRIVE #2D
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-2319
Practice Address - Country:US
Practice Address - Phone:415-585-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT9570291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory