Provider Demographics
NPI:1588940571
Name:SERGEY LYASS MD, PC
Entity type:Organization
Organization Name:SERGEY LYASS MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-623-1786
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 1:3560 E FLAMINGO RD
Practice Address - Street 2:# 105
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-0201
Practice Address - Country:US
Practice Address - Phone:702-454-8712
Practice Address - Fax:702-434-5865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-23
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14103208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI 29283Medicare UPIN
CAA80181Medicare PIN