Healthcare Provider Details

I. General information

NPI: 1215594692
Provider Name (Legal Business Name): SHANT TOMASSIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W ROUTE 66 STE 201
GLENDORA CA
91740-4335
US

IV. Provider business mailing address

1115 S SUNSET AVE
WEST COVINA CA
91790-3940
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-0900
  • Fax: 626-963-9663
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA179858
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberPTL1731
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA179858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: