Provider Demographics
NPI:1598758062
Name:BAGDASARIAN, BORIS (DO)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:BAGDASARIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:541 W COLORADO ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3640
Mailing Address - Country:US
Mailing Address - Phone:323-254-0046
Mailing Address - Fax:323-488-9782
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-409-0105
Practice Address - Fax:818-409-0151
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A6598207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF89522Medicare UPIN
CAW11605BMedicare ID - Type Unspecified