Provider Demographics
NPI:1124188628
Name:YADEGARIAN, HERACH (MD)
Entity Type:Individual
Prefix:MR
First Name:HERACH
Middle Name:
Last Name:YADEGARIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S. CENTRAL AVE.
Mailing Address - Street 2:SUITE 308
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4644
Mailing Address - Country:US
Mailing Address - Phone:818-240-8767
Mailing Address - Fax:818-502-0254
Practice Address - Street 1:800 S. CENTRAL AVE.
Practice Address - Street 2:SUITE 308
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4644
Practice Address - Country:US
Practice Address - Phone:818-240-8767
Practice Address - Fax:818-502-0254
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49305208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A493050Medicaid
CAE86785Medicare UPIN
CA00A493050Medicaid