Healthcare Provider Details

I. General information

NPI: 1952516627
Provider Name (Legal Business Name): LOS ANGELES HEMATOLOGY-ONCOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER STE 200
GLENDALE CA
91206-4073
US

IV. Provider business mailing address

1505 WILSON TER STE 210
GLENDALE CA
91206-4074
US

V. Phone/Fax

Practice location:
  • Phone: 323-910-4060
  • Fax: 818-279-0818
Mailing address:
  • Phone: 818-696-6994
  • Fax: 844-292-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. BORIS BAGDASARIAN
Title or Position: PARTNER
Credential: D.O.
Phone: 818-696-6994