MEDICARE: DR. JOSEPH KHATCHADOURIAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	42191	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z136590	OTHER	AZ	MEDICARE PTAN

General Provider Information

NPI Number	:	1477501161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH KHATCHADOURIAN M.D.

Provider Business Mailing Address
First Line	:	4140 E BASELINE RD STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4413
Country	:	US
Telephone Number	:	480-719-6229
Fax Number	:

Provider Business Practice Location Address
First Line	:	4140 E BASELINE RD STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4413
Country	:	US
Telephone Number	:	480-719-6229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	04/17/2015

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