Provider Demographics
NPI:1902814973
Name:OSIPOV, RAISA J (MD)
Entity Type:Individual
Prefix:DR
First Name:RAISA
Middle Name:J
Last Name:OSIPOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:29600 ISLAND VIEW DR
Mailing Address - Street 2:109
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-4650
Mailing Address - Country:US
Mailing Address - Phone:310-541-8676
Mailing Address - Fax:310-541-8676
Practice Address - Street 1:5205 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3144
Practice Address - Country:US
Practice Address - Phone:310-874-1807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA69109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA120140809000112OtherPECOS ENROLLMENTID
CA539563835OtherPECOS PAC ID
CA5665534Medicaid
CA539563835OtherPECOS PAC ID
CA5665534Medicaid