Provider Demographics
NPI:1629288329
Name:GHAZARYAN, GEVORG (MD)
Entity Type:Individual
Prefix:
First Name:GEVORG
Middle Name:
Last Name:GHAZARYAN
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-727-3256
Mailing Address - Fax:
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
Practice Address - Country:US
Practice Address - Phone:510-727-3256
Practice Address - Fax:510-727-3107
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104857207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA104857OtherSTATE LICENSE
CABLUE SHIELDOther0A1048570
CAA104857OtherSTATE LICENSE