Healthcare Provider Details

I. General information

NPI: 1891348793
Provider Name (Legal Business Name): MIKAYEL GRIGORYAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 E CHEVY CHASE DR STE 201
GLENDALE CA
91206-4056
US

IV. Provider business mailing address

3310 SPARR BLVD
GLENDALE CA
91208-1663
US

V. Phone/Fax

Practice location:
  • Phone: 818-265-2245
  • Fax:
Mailing address:
  • Phone: 650-995-3193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MIKAYEL GRIGORYAN
Title or Position: PRESIDENT
Credential: MD
Phone: 650-995-3193