Healthcare Provider Details

I. General information

NPI: 1710177845
Provider Name (Legal Business Name): ANDRE PANOSSIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ANDRE A PANOSSIAN M.D.

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 09/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CONGRESS ST STE 402
PASADENA CA
91105-3024
US

IV. Provider business mailing address

39 CONGRESS ST STE 402
PASADENA CA
91105-3024
US

V. Phone/Fax

Practice location:
  • Phone: 800-958-3778
  • Fax: 800-958-3778
Mailing address:
  • Phone: 800-958-3778
  • Fax: 800-958-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA76052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: