MEDICARE: DR. BORIS MARDIAN OD.

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	152W00000X	Optometrist	11702	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477579506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BORIS MARDIAN OD.

Provider Business Mailing Address
First Line	:	113 E BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1006
Country	:	US
Telephone Number	:	818-241-7719
Fax Number	:	818-241-0507

Provider Business Practice Location Address
First Line	:	113 E BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1006
Country	:	US
Telephone Number	:	818-241-7719
Fax Number	:	818-241-0507

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/21/2020

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