Healthcare Provider Details

I. General information

NPI: 1194165308
Provider Name (Legal Business Name): ILYA SABSOVICH MD INC A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 CAMINO VERDE DR SUITE L
SAN JOSE CA
95119-1401
US

IV. Provider business mailing address

13290 LENNOX WAY
LOS ALTOS HILLS CA
94022-3542
US

V. Phone/Fax

Practice location:
  • Phone: 650-580-0939
  • Fax:
Mailing address:
  • Phone: 650-580-0939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA115064
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA115064
License Number StateCA

VIII. Authorized Official

Name: ILYA SABSOVICH
Title or Position: PRESIDENT
Credential: MD
Phone: 650-580-0939