MEDICARE: MISSAK KLTCHIAN MD INC.

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	207R00000X	Internal Medicine Physician	A52368	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1578901237	OTHER	CA	MEDICARE
3	1255359840	OTHER	CA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932695079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSAK KLTCHIAN MD INC.

Provider Business Mailing Address
First Line	:	4645 HOLLYWOOD BLVD STE 2/4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-5455
Country	:	US
Telephone Number	:	323-661-4500
Fax Number	:	323-661-3260

Provider Business Practice Location Address
First Line	:	4645 HOLLYWOOD BLVD STE 2/4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-5455
Country	:	US
Telephone Number	:	323-661-4500
Fax Number	:	323-661-3260

Authorized Official
Title or Position	:	MD / PRESIDENT
Name	:	DR. MISSAK KLTCHIAN
Credential	:	MD
Telephone Number	:	323-661-4500

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	07/02/2018

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