Provider Demographics
NPI:1497846638
Name:VAISMAN, SOFIA (MD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:VAISMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22600 VENTURA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1430
Mailing Address - Country:US
Mailing Address - Phone:818-225-1255
Mailing Address - Fax:
Practice Address - Street 1:22600 VENTURA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1430
Practice Address - Country:US
Practice Address - Phone:818-225-1255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA036979207QA0505X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A369790Medicaid
CA010017655OtherRAILROAD MEDICARE
CA00A369790Medicaid
CA010017655OtherRAILROAD MEDICARE