=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992739957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIKHAIL VIZEL, MD, MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 VAN NUYS BLVD STE 200
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-580-2285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13790 HIGHTOP ST
-----------------------------------------------------
City | MOORPARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93021-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-580-2364
-----------------------------------------------------
Fax | 818-986-9786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MIKHAIL VIZEL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-716-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A53626
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------