Provider Demographics
NPI:1518963578
Name:DAVIDIAN, MARK MIHRAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MIHRAN
Last Name:DAVIDIAN
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:PO BOX 678510
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8510
Mailing Address - Country:US
Mailing Address - Phone:559-272-2934
Mailing Address - Fax:
Practice Address - Street 1:2801 K ST
Practice Address - Street 2:#502
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5120
Practice Address - Country:US
Practice Address - Phone:877-515-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG735332085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G735330Medicaid
CAF43222Medicare UPIN
CA00G735330Medicare ID - Type Unspecified