Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | A40429 | CA |
NPI | 1033208269 |
---|---|
Provider Name | Raisa Heifets |
First Address | Los Angeles, CA 90042-3503 |
Second Address | Los Angeles, CA 90042-3503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A404290 | (05) | CA |
A29120 | (02) | CA |