Provider Demographics
NPI:1639102254
Name:MAMIKUNIAN, CREED K (MD)
Entity Type:Individual
Prefix:DR
First Name:CREED
Middle Name:K
Last Name:MAMIKUNIAN
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 1:2401 E 42ND AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5205
Mailing Address - Country:US
Mailing Address - Phone:907-562-1860
Mailing Address - Fax:907-562-1865
Practice Address - Street 1:2401 E 42ND AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5205
Practice Address - Country:US
Practice Address - Phone:907-562-1860
Practice Address - Fax:907-562-1865
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2517207Y00000X
CAA48276207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2517Medicaid
AKMD2517Medicaid
E70235Medicare UPIN