Provider Demographics
NPI:1477579506
Name:MARDIAN, BORIS (OD)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:MARDIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1006
Mailing Address - Country:US
Mailing Address - Phone:818-241-7719
Mailing Address - Fax:818-241-0507
Practice Address - Street 1:113 E BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1006
Practice Address - Country:US
Practice Address - Phone:818-241-7719
Practice Address - Fax:818-241-0507
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00117020Medicaid
CA00117020Medicaid