Healthcare Provider Details

I. General information

NPI: 1104228097
Provider Name (Legal Business Name): OLGA VARDANYAN C.N.S., M.D., PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E MAGNOLIA BLVD SUITE 102
BURBANK CA
91502-1153
US

IV. Provider business mailing address

333 E MAGNOLIA BLVD SUITE 102
BURBANK CA
91502-1153
US

V. Phone/Fax

Practice location:
  • Phone: 818-729-0300
  • Fax: 818-729-0400
Mailing address:
  • Phone: 818-729-0300
  • Fax: 818-729-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberCNS16161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: