Healthcare Provider Details

I. General information

NPI: 1871656603
Provider Name (Legal Business Name): AGOP AINTABLIAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 E COLORADO SUITE # A
GLENDALE CA
91205
US

IV. Provider business mailing address

416 E COLORADO SUITE # A
GLENDALE CA
91205
US

V. Phone/Fax

Practice location:
  • Phone: 818-507-1305
  • Fax: 818-507-4786
Mailing address:
  • Phone: 818-507-1305
  • Fax: 818-507-4786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number42615
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number42615
License Number StateCA

VIII. Authorized Official

Name: AGOP AINTABLIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 818-507-1305