Healthcare Provider Details

I. General information

NPI: 1174647192
Provider Name (Legal Business Name): MARK KHAJAG MARKARIAN MD, MSPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WALNUT ST SUITE 400
WELLESLEY MA
02481-2152
US

IV. Provider business mailing address

14847 HAYWARD ST
WHITTIER CA
90603-2048
US

V. Phone/Fax

Practice location:
  • Phone: 781-431-0002
  • Fax: 781-237-2022
Mailing address:
  • Phone: 706-495-7886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number255422
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number130523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: