Basic Information
Provider Information | |||||||||
NPI: | 1770546475 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIHIRI DESILVA-KLEBICKI, D.O., APC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7001 | ||||||||
Address2: |   | ||||||||
City: | TARZANA | ||||||||
State: | CA | ||||||||
PostalCode: | 913577001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188887815 | ||||||||
FaxNumber: | 8187151722 | ||||||||
Practice Location | |||||||||
Address1: | 15107 VANOWEN ST | ||||||||
Address2: |   | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914054542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187826600 | ||||||||
FaxNumber: | 8187151722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2006 | ||||||||
LastUpdateDate: | 09/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DESILVA-KLEBICKI | ||||||||
AuthorizedOfficialFirstName: | MIHIRI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECT OWNER | ||||||||
AuthorizedOfficialTelephone: | 8188887815 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 20A9248 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 20A9248 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | W20A9248A | 01 | CA | MEDICARE PPIN | OTHER | 00AX92480 | 01 | CA | BLUE SHIELD OF CA | OTHER |