Healthcare Provider Details

I. General information

NPI: 1780117523
Provider Name (Legal Business Name): HARI AVEDISSIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2017
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S CENTRAL AVE
GLENDALE CA
91204-2594
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 818-502-1900
  • Fax:
Mailing address:
  • Phone: 888-854-3822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A18986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: