Healthcare Provider Details

I. General information

NPI: 1134743206
Provider Name (Legal Business Name): ANI MNATSAKANIAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE STE 411
PASADENA CA
91105-3155
US

IV. Provider business mailing address

14650 AVIATION BLVD STE 200
HAWTHORNE CA
90250-6670
US

V. Phone/Fax

Practice location:
  • Phone: 323-306-9632
  • Fax:
Mailing address:
  • Phone: 323-306-9632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5151014683
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number20A23436
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: