Healthcare Provider Details

I. General information

NPI: 1063414027
Provider Name (Legal Business Name): WANES BARSEMIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 E 120-TH STREET MARTIN LUTHER KING COM HOSPITAL
LOS ANGELES CA
90059
US

IV. Provider business mailing address

1680 E 120-TH STREET MLKCH
LOS ANGELES CA
90059
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-8000
  • Fax: 424-338-8962
Mailing address:
  • Phone: 424-338-8000
  • Fax: 424-338-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number047393
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number66186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: