Provider Demographics
NPI:1306860465
Name:MINASIAN, RAFFI R (MD)
Entity Type:Individual
Prefix:
First Name:RAFFI
Middle Name:R
Last Name:MINASIAN
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 1:1500 S CENTRAL AVE
Mailing Address - Street 2:SUITE300
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2530
Mailing Address - Country:US
Mailing Address - Phone:818-242-0475
Mailing Address - Fax:818-662-0260
Practice Address - Street 1:1500 S CENTRAL AVE
Practice Address - Street 2:SUITE300
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2530
Practice Address - Country:US
Practice Address - Phone:818-242-0475
Practice Address - Fax:818-662-0260
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52887207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G528870Medicaid
CAE58214Medicare UPIN
CA00G528870Medicaid