Healthcare Provider Details

I. General information

NPI: 1063115525
Provider Name (Legal Business Name): KRISTINA TOMBULYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W GOLDLEAF CIR FL 2
LOS ANGELES CA
90056-1658
US

IV. Provider business mailing address

5100 W GOLDLEAF CIR FL 2
LOS ANGELES CA
90056-1658
US

V. Phone/Fax

Practice location:
  • Phone: 323-293-7171
  • Fax: 310-348-3716
Mailing address:
  • Phone: 323-293-7171
  • Fax: 310-348-3716

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 NumberA207393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: