Healthcare Provider Details

I. General information

NPI: 1982791562
Provider Name (Legal Business Name): RAFAYEL GEVORKIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5129 W SUNSET BLVD
LOS ANGELES CA
90027-5715
US

IV. Provider business mailing address

5129 W SUNSET BLVD
LOS ANGELES CA
90027-5715
US

V. Phone/Fax

Practice location:
  • Phone: 323-663-9009
  • Fax: 323-663-5550
Mailing address:
  • Phone: 323-663-9009
  • Fax: 323-663-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberA41672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: