Healthcare Provider Details

I. General information

NPI: 1104076785
Provider Name (Legal Business Name): LEONID IZEVICH GROYSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LEONID GROYSMAN MD

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17360 BROOKHURST ST.
FOUNTAIN VALLEY CA
92708-3720
US

IV. Provider business mailing address

17360 BROOKHURST ST.
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 877-844-0012
  • Fax: 714-665-4680
Mailing address:
  • Phone: 877-844-0012
  • Fax: 714-665-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA112765
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA112765
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberA112765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: