Healthcare Provider Details

I. General information

NPI: 1609233121
Provider Name (Legal Business Name): VATCHE B. BARDAKJIAN, M.D, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1577 E CHEVY CHASE DR STE 250
GLENDALE CA
91206-4172
US

IV. Provider business mailing address

1577 E CHEVY CHASE DR STE 250
GLENDALE CA
91206-4172
US

V. Phone/Fax

Practice location:
  • Phone: 818-247-4894
  • Fax: 818-247-4163
Mailing address:
  • Phone: 818-247-4894
  • Fax: 818-247-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA45955
License Number StateCA

VIII. Authorized Official

Name: VATCHE B BARDAKJIAN
Title or Position: CEO
Credential: M.D
Phone: 818-247-4894