Healthcare Provider Details

I. General information

NPI: 1194310151
Provider Name (Legal Business Name): LOS ANGELES HEMATOLOGY-ONCOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 W OLYMPIC BLVD STE 105
LOS ANGELES CA
90036-4680
US

IV. Provider business mailing address

541 W COLORADO ST STE 205
GLENDALE CA
91204-3640
US

V. Phone/Fax

Practice location:
  • Phone: 323-489-6010
  • Fax: 833-402-0866
Mailing address:
  • Phone: 323-254-0046
  • Fax: 323-488-9782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: BORIS BAGDASARIAN
Title or Position: AUTHORIZED OFFICIAL
Credential: DO
Phone: 818-409-0105