=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851599534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZA LADYZHENSKY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 SOUTH ORANGE DRIVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-206-9628
-----------------------------------------------------
Fax | 323-549-9629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 SOUTH ORANGE DRIVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-206-9628
-----------------------------------------------------
Fax | 323-549-9629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202C00000X
-----------------------------------------------------
Taxonomy Name | Independent Medical Examiner Physician
-----------------------------------------------------
License Number | A38784
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------