Provider Demographics
NPI:1033247515
Name:MISHIDZHYAN, MARTIROS
Entity Type:Individual
Prefix:
First Name:MARTIROS
Middle Name:
Last Name:MISHIDZHYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5709
Mailing Address - Country:US
Mailing Address - Phone:323-661-8004
Mailing Address - Fax:818-507-0314
Practice Address - Street 1:5207 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5709
Practice Address - Country:US
Practice Address - Phone:323-661-8004
Practice Address - Fax:818-507-0314
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5702430001171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5702430001Medicare NSC