Provider Demographics
NPI:1962922690
Name:LYASHEVSKY, CLARA
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:LYASHEVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2428 SANTA MONICA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2046
Practice Address - Country:US
Practice Address - Phone:310-998-5868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2021-09-10
Deactivation Date:2018-04-02
Deactivation Code:
Reactivation Date:2018-05-21
Provider Licenses
StateLicense IDTaxonomies
CA20A17992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine