Healthcare Provider Details

I. General information

NPI: 1497863278
Provider Name (Legal Business Name): GASSER MAHGR HATHOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14445 OLIVEVIEW DR
SYLMAR CA
91342
US

IV. Provider business mailing address

1622 SAN GABRIEL AVE
GLENDALE CA
91208
US

V. Phone/Fax

Practice location:
  • Phone: 818-364-1555
  • Fax:
Mailing address:
  • Phone: 818-242-7350
  • Fax: 818-242-7350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberG66261
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG66261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: