Healthcare Provider Details

I. General information

NPI: 1205323219
Provider Name (Legal Business Name): MICHAEL KHANJYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

7777 ALVARADO RD STE 108
LA MESA CA
91942-8245
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4005
  • Fax:
Mailing address:
  • Phone: 619-460-2770
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA164122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: