Healthcare Provider Details

I. General information

NPI: 1538100094
Provider Name (Legal Business Name): PACIFIC MULTI SPECIALTY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S BRAND BLVD SUITE 200
GLENDALE CA
91204-1342
US

IV. Provider business mailing address

127 S BRAND BLVD SUITE 200
GLENDALE CA
91204-1342
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-9100
  • Fax: 818-551-9634
Mailing address:
  • Phone: 818-241-9100
  • Fax: 818-551-9634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License NumberA54463
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License NumberA53748
License Number StateCA

VIII. Authorized Official

Name: DR. VAHAN MADATOVIAN
Title or Position: OWNER
Credential: MD
Phone: 818-241-9100