MEDICARE: TATEVIK BALASANYAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085U0001X	Diagnostic Ultrasound Physician	254139	CA

General Provider Information

NPI Number	:	1194392076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATEVIK BALASANYAN

Provider Business Mailing Address
First Line	:	17251 GRESHAM ST
Second Line	:
City	:	SHERWOOD FOREST
State	:	CA
Zip	:	91325-3207
Country	:	US
Telephone Number	:	818-614-2973
Fax Number	:

Provider Business Practice Location Address
First Line	:	17251 GRESHAM ST
Second Line	:
City	:	SHERWOOD FOREST
State	:	CA
Zip	:	91325-3207
Country	:	US
Telephone Number	:	818-614-2973
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2021
Last Update Date	:	06/08/2021

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