Healthcare Provider Details

I. General information

NPI: 1902095854
Provider Name (Legal Business Name): MENACHEM WAKSLAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16119 VANOWEN ST
VAN NUYS CA
91406-4822
US

IV. Provider business mailing address

16119 VANOWEN ST
VAN NUYS CA
91406-4822
US

V. Phone/Fax

Practice location:
  • Phone: 818-904-6782
  • Fax: 818-904-5896
Mailing address:
  • Phone: 818-904-6782
  • Fax: 818-904-5896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number240477-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA114088
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number240477-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberA114088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: