Provider Demographics
NPI:1467406330
Name:KHUBESRIAN, MARINA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:KHUBESRIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1125 E BROADWAY
Mailing Address - Street 2:BOX 71
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1315
Mailing Address - Country:US
Mailing Address - Phone:818-240-8659
Mailing Address - Fax:818-242-8659
Practice Address - Street 1:801 S CHEVY CHASE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4431
Practice Address - Country:US
Practice Address - Phone:818-240-8659
Practice Address - Fax:818-242-8659
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG77513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G775130Medicaid
CA00G775130Medicaid
CAWG77513BMedicare ID - Type Unspecified