Provider Demographics
NPI:1447446125
Name:DIMITRY B. GOUFMAN, MD, INC.
Entity type:Organization
Organization Name:DIMITRY B. GOUFMAN, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIMITRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-532-6201
Mailing Address - Street 1:705 W LA VETA AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4447
Mailing Address - Country:US
Mailing Address - Phone:714-532-6201
Mailing Address - Fax:714-532-6563
Practice Address - Street 1:705 W LA VETA AVE STE 115
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4447
Practice Address - Country:US
Practice Address - Phone:714-532-6201
Practice Address - Fax:714-532-6563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52758207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty