Healthcare Provider Details

I. General information

NPI: 1891306502
Provider Name (Legal Business Name): EMIN MIKAELIAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 11/14/2020
Certification Date: 11/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E COLORADO BLVD STE 128
PASADENA CA
91101-2267
US

IV. Provider business mailing address

345 PIONEER DR UNIT 101W
GLENDALE CA
91203-2741
US

V. Phone/Fax

Practice location:
  • Phone: 626-463-1314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: