Healthcare Provider Details

I. General information

NPI: 1659721850
Provider Name (Legal Business Name): SAMVEL KESHISHYAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S CENTRAL AVE STE 202
GLENDALE CA
91204-4375
US

IV. Provider business mailing address

800 S CENTRAL AVE STE 202
GLENDALE CA
91204-4375
US

V. Phone/Fax

Practice location:
  • Phone: 818-927-3668
  • Fax: 818-927-3686
Mailing address:
  • Phone: 818-927-3668
  • Fax: 818-927-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: