1174814701 NPI number — DR. ARISS DERHOVANESSIAN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174814701 NPI number — DR. ARISS DERHOVANESSIAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERHOVANESSIAN
Provider First Name:
ARISS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DER HOVANESSIAN
Provider Other First Name:
ARISS
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174814701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10833 LE CONTE AVE
Provider Second Line Business Mailing Address:
UCLA CENTER FOR HEALTH SCIENCES 37-131, BOX 951690
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90095-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-825-8599
Provider Business Mailing Address Fax Number:
310-794-7073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10833 LE CONTE AVE
Provider Second Line Business Practice Location Address:
UCLA CENTER FOR HEALTH SCIENCES 37-131, BOX 951690
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-1690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-8599
Provider Business Practice Location Address Fax Number:
310-794-7073
Provider Enumeration Date:
04/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  A100344 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0200X , with the licence number: A100344 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1174814701 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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