Provider Demographics
NPI:1437188299
Name:PERSIDSKY, IGOR (MD)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:PERSIDSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5434 HERON BAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4821
Mailing Address - Country:US
Mailing Address - Phone:562-985-0619
Mailing Address - Fax:562-498-4601
Practice Address - Street 1:5434 HERON BAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-4821
Practice Address - Country:US
Practice Address - Phone:562-985-0619
Practice Address - Fax:562-498-4601
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A541211Medicaid
CA00A541211Medicaid
CAA54121Medicare PIN