Provider Demographics
NPI:1598911497
Name:BORIS VAISMAN MEDICAL COPORATION
Entity Type:Organization
Organization Name:BORIS VAISMAN MEDICAL COPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-225-1255
Mailing Address - Street 1:4932 CHIMINEAS AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4302
Mailing Address - Country:US
Mailing Address - Phone:818-225-1255
Mailing Address - Fax:818-225-8646
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:818-225-8646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2901737Medicaid