Provider Demographics
NPI:1548295116
Name:STOLETNIY, LISET (MD)
Entity type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:STOLETNIY
Suffix:
Gender:F
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:FILE 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:909-558-8590
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:#1617
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51258207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A512580Medicaid
CA00A512580Medicare PIN
CA00A512580Medicaid