Basic Information
Provider Information | |||||||||
NPI: | 1003841222 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EMGUSHOV | ||||||||
FirstName: | OLGA | ||||||||
MiddleName: | DORJIMA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD,MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3300 S FISKE BLVD | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 329554306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3214341981 | ||||||||
FaxNumber: | 3219517408 | ||||||||
Practice Location | |||||||||
Address1: | 1350 HICKORY ST | ||||||||
Address2: |   | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329013224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3214341771 | ||||||||
FaxNumber: | 3214341775 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 09/25/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 023639 | LA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD 14803 | HI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | ME94076 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 023639 | LA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD14803 | HI | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208M00000X | ME94076 | FL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 020269400 | 05 | FL |   | MEDICAID | DK923X | 01 | FL | MEDICARE | OTHER |