Basic Information
| Provider Information | |||||||||
| NPI: | 1629098116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORODULIN-SMIK | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EMBARCADERO CTR STE 19002ND | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941113628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156586791 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 803 ELEVENTH AVE | ||||||||
| Address2: | |||||||||
| City: | SUNNYVALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940894731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082281025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC 27390 | CA | N | Chiropractic Providers | Chiropractor | 363A00000X | PA22970 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | ZZZ64417Z-30 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | DC0273900 | 05 | CA | MEDICAID |