Healthcare Provider Details

I. General information

NPI: 1952756256
Provider Name (Legal Business Name): LEVON DJENDEREDJIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 SAN MIGUEL DR STE 28
WALNUT CREEK CA
94596-5298
US

IV. Provider business mailing address

1855 SAN MIGUEL DR STE 28
WALNUT CREEK CA
94596-5298
US

V. Phone/Fax

Practice location:
  • Phone: 310-940-3292
  • Fax:
Mailing address:
  • Phone: 310-940-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number298969
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberA172266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: