Provider Demographics
NPI:1295732154
Name:NISENBAUM, ROBERT P (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:P
Last Name:NISENBAUM
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 1:3533 COY DR
Mailing Address - Street 2:SUITE 1609
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4542
Mailing Address - Country:US
Mailing Address - Phone:310-308-0640
Mailing Address - Fax:
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 1609
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-553-7151
Practice Address - Fax:310-286-2184
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-06
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A659030Medicaid
CAA65903Medicare ID - Type Unspecified
CAH16510Medicare UPIN