Healthcare Provider Details

I. General information

NPI: 1124715701
Provider Name (Legal Business Name): RAFFI JOHN KHECHOUMIAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4849 VAN NUYS BLVD STE 205A
SHERMAN OAKS CA
91403-2110
US

IV. Provider business mailing address

PO BOX 841868
LOS ANGELES CA
90084-1868
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-0011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number6165
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number6165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: