Provider Demographics
NPI:1447252218
Name:LEIBZON, ROMAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:LEIBZON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 S BUENA VISTA ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4554
Mailing Address - Country:US
Mailing Address - Phone:818-848-0023
Mailing Address - Fax:818-848-3495
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:818-848-0023
Practice Address - Fax:818-848-3495
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71810207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A718100Medicaid
CA953547028OtherTIN
CAAZ258WMedicare PIN
CA953547028OtherTIN