Healthcare Provider Details

I. General information

NPI: 1114258944
Provider Name (Legal Business Name): EDMOND DERDERIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2010
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 VAN NUYS BLVD STE 308
SHERMAN OAKS CA
91403-1811
US

IV. Provider business mailing address

4955 VAN NUYS BLVD STE 308
SHERMAN OAKS CA
91403-1811
US

V. Phone/Fax

Practice location:
  • Phone: 818-528-1044
  • Fax: 818-817-0845
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA110089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: