Provider Demographics
NPI:1457520009
Name:SELIVERSTOV, MARIA I (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:I
Last Name:SELIVERSTOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 VAN NUYS BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2131
Mailing Address - Country:US
Mailing Address - Phone:818-986-9232
Mailing Address - Fax:818-986-9716
Practice Address - Street 1:4835 VAN NUYS BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2131
Practice Address - Country:US
Practice Address - Phone:818-986-9232
Practice Address - Fax:818-986-9716
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA669382084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A669380Medicaid
G87917Medicare UPIN
CA00A669380Medicaid