Healthcare Provider Details

I. General information

NPI: 1760564272
Provider Name (Legal Business Name): HERMOZ B AYVAZIAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S ADAMS ST
GLENDALE CA
91205-1312
US

IV. Provider business mailing address

110 S ADAMS ST
GLENDALE CA
91205-1312
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-4426
  • Fax: 818-242-4409
Mailing address:
  • Phone: 818-242-4426
  • Fax: 818-242-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: