Provider Demographics
NPI:1316996911
Name:LYASS, SERGEY (MD)
Entity type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:
Last Name:LYASS
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 1:4301 GRIMES PL
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4361
Mailing Address - Country:US
Mailing Address - Phone:818-578-3388
Mailing Address - Fax:310-693-2603
Practice Address - Street 1:4301 GRIMES PL
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4361
Practice Address - Country:US
Practice Address - Phone:310-623-1786
Practice Address - Fax:310-693-5334
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80181208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11542441OtherCAQH ID#
CAA80181Medicare PIN
CA11542441OtherCAQH ID#