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General NPI Number Information
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NPI Number | 1477579506
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Entity Type | Individual
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Provider Name | BORIS MARDIAN OD.
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Gender | Male
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 07/21/2020
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Provider Practice Location Address
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Address Line | 113 E BROADWAY
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City | GLENDALE
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State | CA
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Zip | 91205-1006
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Country | US
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Telephone | 818-241-7719
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Fax | 818-241-0507
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Provider Business Mailing Address
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Address Line | 113 E BROADWAY
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City | GLENDALE
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State | CA
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Zip | 91205-1006
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Country | US
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Telephone | 818-241-7719
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Fax | 818-241-0507
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 11702
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License Number State | CA
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