Provider Demographics
NPI:1639438435
Name:KOVALEV, ILLIA
Entity Type:Individual
Prefix:
First Name:ILLIA
Middle Name:
Last Name:KOVALEV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4533 VAN NUYS BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2950
Mailing Address - Country:US
Mailing Address - Phone:818-849-6755
Mailing Address - Fax:
Practice Address - Street 1:4533 VAN NUYS BLVD STE 302
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2950
Practice Address - Country:US
Practice Address - Phone:818-849-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0002615765-0001-5207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine