Provider Demographics
NPI:1396799532
Name:LIZASO, KNEF V JR
Entity type:Individual
Prefix:
First Name:KNEF
Middle Name:V
Last Name:LIZASO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KNEF
Other - Middle Name:V
Other - Last Name:LIZASO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:28610 CEDARBLUFF DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3114
Mailing Address - Country:US
Mailing Address - Phone:310-529-9028
Mailing Address - Fax:
Practice Address - Street 1:620 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4119
Practice Address - Country:US
Practice Address - Phone:702-388-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11684207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A697790Medicaid
CAWA69779BMedicare PIN
CAWA69779AMedicare PIN
CA00A697790Medicaid