Healthcare Provider Details

I. General information

NPI: 1649572652
Provider Name (Legal Business Name): GAGIK KHOYLYAN, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 N CENTRAL AVE STE 105
GLENDALE CA
91203-3350
US

IV. Provider business mailing address

PO BOX 27206
LOS ANGELES CA
90027-0206
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-2224
  • Fax: 818-244-2261
Mailing address:
  • Phone: 213-385-0675
  • Fax: 213-365-6429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA100597
License Number StateCA

VIII. Authorized Official

Name: DEBBIE DIAZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 213-385-0675