Healthcare Provider Details

I. General information

NPI: 1043371172
Provider Name (Legal Business Name): KAYICHIAN DESPINA, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE SUITE 210
GLENDALE CA
91204-2500
US

IV. Provider business mailing address

1510 S CENTRAL AVE SUITE 210
GLENDALE CA
91204-2500
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-7628
  • Fax: 818-241-7639
Mailing address:
  • Phone: 818-241-7628
  • Fax: 818-241-7639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA052950
License Number StateCA

VIII. Authorized Official

Name: MRS. DESPINA GHABY KAYICHIAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-241-7628