Healthcare Provider Details

I. General information

NPI: 1942571047
Provider Name (Legal Business Name): WASHINGTON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2544 E WASHINGTON BLVD STE C
PASADENA CA
91107-1452
US

IV. Provider business mailing address

2544 E WASHINGTON BLVD STE C
PASADENA CA
91107-1452
US

V. Phone/Fax

Practice location:
  • Phone: 626-398-4069
  • Fax: 626-798-9041
Mailing address:
  • Phone: 626-398-4069
  • Fax: 626-798-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3953
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA55018
License Number StateCA

VIII. Authorized Official

Name: MARINA MANVELYAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-398-4069