Healthcare Provider Details

I. General information

NPI: 1598758062
Provider Name (Legal Business Name): BORIS BAGDASARIAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER SUITE 200
GLENDALE CA
91206-4071
US

IV. Provider business mailing address

541 W COLORADO ST STE 205
GLENDALE CA
91204-3640
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-0105
  • Fax: 818-409-0151
Mailing address:
  • Phone: 323-254-0046
  • Fax: 323-488-9782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number20A6598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: