Provider Demographics
NPI:1194392076
Name:BALASANYAN, TATEVIK
Entity Type:Individual
Prefix:
First Name:TATEVIK
Middle Name:
Last Name:BALASANYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17251 GRESHAM ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:91325-3207
Mailing Address - Country:US
Mailing Address - Phone:818-614-2973
Mailing Address - Fax:
Practice Address - Street 1:17251 GRESHAM ST
Practice Address - Street 2:
Practice Address - City:SHERWOOD FOREST
Practice Address - State:CA
Practice Address - Zip Code:91325-3207
Practice Address - Country:US
Practice Address - Phone:818-614-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2541392085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound