Provider Demographics
NPI:1780992511
Name:MANASHERIAN-YACCOBE, LIOR
Entity type:Individual
Prefix:
First Name:LIOR
Middle Name:
Last Name:MANASHERIAN-YACCOBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 DANIELS DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1165
Mailing Address - Country:US
Mailing Address - Phone:310-948-7600
Mailing Address - Fax:
Practice Address - Street 1:12370 HESPERIA RD STE 6
Practice Address - Street 2:HERITAGE VICTOR VALLEY MEDICAL GROUP
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4787
Practice Address - Country:US
Practice Address - Phone:760-245-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122933208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN