Healthcare Provider Details

I. General information

NPI: 1740540244
Provider Name (Legal Business Name): SEVAG BASTIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER STE 310
GLENDALE CA
91206-4073
US

IV. Provider business mailing address

1505 WILSON TER STE 310
GLENDALE CA
91206-4073
US

V. Phone/Fax

Practice location:
  • Phone: 818-841-3936
  • Fax:
Mailing address:
  • Phone: 818-841-3936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA147241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: