Provider Demographics
NPI:1740296136
Name:NISS, ALEXANDER I (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:I
Last Name:NISS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 RIVERSIDE DR APT 301
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2459
Mailing Address - Country:US
Mailing Address - Phone:818-761-6323
Mailing Address - Fax:
Practice Address - Street 1:13739 RIVERSIDE DR STE B
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2417
Practice Address - Country:US
Practice Address - Phone:818-385-0001
Practice Address - Fax:818-385-0081
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA963122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA160305Medicare UPIN