Healthcare Provider Details

I. General information

NPI: 1548535289
Provider Name (Legal Business Name): GREG HAROUTUNIAN,MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 S GLENDALE AVE
GLENDALE CA
91205-3349
US

IV. Provider business mailing address

311 S REXFORD DR
BEVERLY HILLS CA
90212-4607
US

V. Phone/Fax

Practice location:
  • Phone: 310-282-9910
  • Fax:
Mailing address:
  • Phone: 310-282-9910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC54033
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberC54033
License Number StateCA

VIII. Authorized Official

Name: DR. GAGIK GREG HAROUTUNIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 310-282-9910