Healthcare Provider Details

I. General information

NPI: 1548962566
Provider Name (Legal Business Name): MANUSH GHAZARYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

IV. Provider business mailing address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-4500
  • Fax: 707-994-2401
Mailing address:
  • Phone: 707-995-4500
  • Fax: 707-994-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA206733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: