Provider Demographics
NPI:1861422750
Name:LEYBOVICH, OLEG (MPT)
Entity type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:LEYBOVICH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 WILSHIRE BLVD
Mailing Address - Street 2:101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5201
Mailing Address - Country:US
Mailing Address - Phone:323-938-4460
Mailing Address - Fax:323-938-4409
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-938-4460
Practice Address - Fax:323-938-4409
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ07700Medicare UPIN
CAPT24743Medicare ID - Type UnspecifiedPROVIDER #