Provider Demographics
NPI:1447396809
Name:SHAHNAZARIAN, VACHIK (MD)
Entity Type:Individual
Prefix:
First Name:VACHIK
Middle Name:
Last Name:SHAHNAZARIAN
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 1:1030 S GLENDALE AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2866
Mailing Address - Country:US
Mailing Address - Phone:818-291-4041
Mailing Address - Fax:818-291-4047
Practice Address - Street 1:1030 S GLENDALE AVE STE 304
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2866
Practice Address - Country:US
Practice Address - Phone:818-291-4041
Practice Address - Fax:818-291-4047
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84308174400000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A843080Medicaid
CAA84308Medicare ID - Type Unspecified
CA00A843080Medicaid