Healthcare Provider Details

I. General information

NPI: 1043415383
Provider Name (Legal Business Name): DIANA DERMENDJIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 W RIVERSIDE DR
BURBANK CA
91505-4044
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 818-556-2700
  • Fax: 818-295-3450
Mailing address:
  • Phone: 310-301-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: