Healthcare Provider Details

I. General information

NPI: 1447376454
Provider Name (Legal Business Name): RAFFI TACHDJIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST STE 380
SANTA MONICA CA
90404
US

IV. Provider business mailing address

1301 20TH ST STE 380
SANTA MONICA CA
90404-2087
US

V. Phone/Fax

Practice location:
  • Phone: 310-998-0060
  • Fax: 310-998-0063
Mailing address:
  • Phone: 310-998-0060
  • Fax: 109-980-0633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberA88034
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA88034
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: