Provider Demographics
NPI:1629098116
Name:BORODULIN-SMIK, IRINA (PAC, DC)
Entity type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:BORODULIN-SMIK
Suffix:
Gender:F
Credentials:PAC, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 N SHORELINE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-1374
Mailing Address - Country:US
Mailing Address - Phone:408-810-0404
Mailing Address - Fax:
Practice Address - Street 1:1674 N SHORELINE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1374
Practice Address - Country:US
Practice Address - Phone:650-386-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 27390111N00000X
CAPA22970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64417Z-30OtherBLUE SHIELD OF CALIFORNIA
CADC0273900Medicaid
CADC0273900Medicaid
CADC0273900Medicaid
CAU91087Medicare UPIN