1760564272 NPI number — DR. HERMOZ B AYVAZIAN DPM

Table of content: DR. HERMOZ B AYVAZIAN DPM (NPI 1760564272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760564272 NPI number — DR. HERMOZ B AYVAZIAN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AYVAZIAN
Provider First Name:
HERMOZ
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760564272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 S ADAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91205-1312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-242-4426
Provider Business Mailing Address Fax Number:
818-242-4409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 S ADAMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91205-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-242-4426
Provider Business Practice Location Address Fax Number:
818-242-4409
Provider Enumeration Date:
10/20/2006

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: 213ES0103X , with the licence number:  E3761 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000E37610 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: E3761 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4320950001 . This is a "DMERC ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05D0856782 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 200858800 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ60226Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 480027586 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 954745477 . This is a "TAX ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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