Healthcare Provider Details

I. General information

NPI: 1841298775
Provider Name (Legal Business Name): MARIA I. SELIVERSTOV, MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4835 VAN NUYS BLVD #104
SHERMAN OAKS CA
91403
US

IV. Provider business mailing address

4835 VAN NUYS BLVD #104
SHERMAN OAKS CA
91403
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-9232
  • Fax: 818-986-9716
Mailing address:
  • Phone: 818-986-9232
  • Fax: 818-986-9716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberA066938
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA066938
License Number StateCA

VIII. Authorized Official

Name: MARIA I. SELIVERSTOV
Title or Position: CEO
Credential: MD
Phone: 818-986-9232