Healthcare Provider Details

I. General information

NPI: 1578770426
Provider Name (Legal Business Name): ANDRE ABOOLIAN M D A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SOUTH SPALDING DRIVE #200
BEVERLY HILLS CA
90212
US

IV. Provider business mailing address

1146 NORTH CENTRAL AVE #101
GLENDALE CA
91202
US

V. Phone/Fax

Practice location:
  • Phone: 310-888-8862
  • Fax: 310-888-8711
Mailing address:
  • Phone: 310-888-8862
  • Fax: 310-888-8711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA81347
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA81347
License Number StateCA

VIII. Authorized Official

Name: DR. ANDRE ABOOLIAN
Title or Position: OWNER
Credential: M.D.
Phone: 310-888-8862