Provider Demographics
NPI:1699872242
Name:MAGGIOTTO, LIESBETH VANDERVELDE (MD)
Entity type:Individual
Prefix:MRS
First Name:LIESBETH
Middle Name:VANDERVELDE
Last Name:MAGGIOTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LIESBETH
Other - Middle Name:
Other - Last Name:VANDERVELDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4261 BEETHOVEN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5705
Mailing Address - Country:US
Mailing Address - Phone:310-745-0550
Mailing Address - Fax:310-745-0550
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS, 3A-108
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:818-364-3234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88506208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics