Provider Demographics
NPI:1992739957
Name:MIKHAIL VIZEL, MD, MEDICAL CORPORATION
Entity type:Organization
Organization Name:MIKHAIL VIZEL, MD, MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-716-2100
Mailing Address - Street 1:13790 HIGHTOP ST
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-5053
Mailing Address - Country:US
Mailing Address - Phone:818-580-2364
Mailing Address - Fax:818-986-9786
Practice Address - Street 1:5000 VAN NUYS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1717
Practice Address - Country:US
Practice Address - Phone:818-580-2285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A0536260Medicaid
CA0A0536260Medicaid