Healthcare Provider Details

I. General information

NPI: 1457770273
Provider Name (Legal Business Name): ALBERT ANTONYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24520 HAWTHORNE BLVD STE 240
TORRANCE CA
90505-6849
US

IV. Provider business mailing address

28625 S WESTERN AVE # 55
RANCHO PALOS VERDES CA
90275-0810
US

V. Phone/Fax

Practice location:
  • Phone: 310-300-6206
  • Fax: 310-919-3703
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA156298
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA156298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: