Provider Demographics
NPI:1578514147
Name:ISAAK VAYSBERG
Entity Type:Organization
Organization Name:ISAAK VAYSBERG
Other - Org Name:IMIG SONOMED DIAGNOSTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAAK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:ARDMS, RVT,RDCS
Authorized Official - Phone:818-681-6100
Mailing Address - Street 1:18455 BURBANK BLVD
Mailing Address - Street 2:STE.206
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2803
Mailing Address - Country:US
Mailing Address - Phone:818-757-0975
Mailing Address - Fax:818-757-0903
Practice Address - Street 1:18455 BURBANK BLVD
Practice Address - Street 2:STE.206
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2803
Practice Address - Country:US
Practice Address - Phone:818-757-0975
Practice Address - Fax:818-757-0903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATG195293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG-195Medicare ID - Type Unspecified