Healthcare Provider Details

I. General information

NPI: 1578563540
Provider Name (Legal Business Name): VARTAN IGIDBASHIAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 ROBERTS RD
NEWTOWN SQUARE PA
19073-2011
US

IV. Provider business mailing address

41 ROBERTS RD
NEWTOWN SQUARE PA
19073-2011
US

V. Phone/Fax

Practice location:
  • Phone: 610-306-0453
  • Fax: 610-356-7403
Mailing address:
  • Phone: 610-306-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC20006395
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: