Provider Demographics
NPI:1326186636
Name:DAVID G DAVTYAN MD INC A PROFESSIONAL MEDICALCORP
Entity Type:Organization
Organization Name:DAVID G DAVTYAN MD INC A PROFESSIONAL MEDICALCORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVTYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-546-1500
Mailing Address - Street 1:1141 N BRAND BLVD
Mailing Address - Street 2:300
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2511
Mailing Address - Country:US
Mailing Address - Phone:818-546-1500
Mailing Address - Fax:818-546-1501
Practice Address - Street 1:1141 N BRAND BLVD STE 300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2578
Practice Address - Country:US
Practice Address - Phone:818-546-1500
Practice Address - Fax:818-546-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70030208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF02342Medicare UPIN