Healthcare Provider Details

I. General information

NPI: 1780068189
Provider Name (Legal Business Name): PRO SURGICAL INC A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE STE 200
GLENDALE CA
91204-2588
US

IV. Provider business mailing address

501 W GLENOAKS BLVD STE 10-819
GLENDALE CA
91202-2896
US

V. Phone/Fax

Practice location:
  • Phone: 818-247-2000
  • Fax: 818-247-2121
Mailing address:
  • Phone: 818-247-2000
  • Fax: 818-247-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA92473
License Number StateNC

VIII. Authorized Official

Name: DR. GEVORG MUTAFYAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-247-2000