Provider Demographics
NPI:1598937468
Name:GRIGORIAN, ELA (MD)
Entity Type:Individual
Prefix:
First Name:ELA
Middle Name:
Last Name:GRIGORIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 E BROADWAY # 71
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1315
Mailing Address - Country:US
Mailing Address - Phone:818-790-1088
Mailing Address - Fax:
Practice Address - Street 1:1818 VERDUGO BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1408
Practice Address - Country:US
Practice Address - Phone:818-790-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A101344Medicaid