Provider Demographics
NPI:1295863124
Name:OKTANYAN, MARO (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARO
Middle Name:
Last Name:OKTANYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 S GLENDALE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-243-0333
Mailing Address - Fax:818-243-3553
Practice Address - Street 1:1259 S GLENDALE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-243-0333
Practice Address - Fax:818-243-3553
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A532540Medicaid
F84401Medicare UPIN
CAA53254Medicare ID - Type Unspecified