Provider Demographics
NPI:1891976189
Name:VAISMAN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VAISMAN
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 1:12660 RIVERSIDE DR
Mailing Address - Street 2:STE 310
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3429
Mailing Address - Country:US
Mailing Address - Phone:818-755-0391
Mailing Address - Fax:818-753-8165
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:STE 310
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-755-0391
Practice Address - Fax:818-753-8165
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38899207Q00000X, 207QG0300X, 2085R0202X, 2085U0001X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A388990Medicaid
CAA38899Medicare PIN
CA00A388990Medicaid