Provider Demographics
NPI:1649572652
Name:GAGIK KHOYLYAN, M.D., INC.
Entity Type:Organization
Organization Name:GAGIK KHOYLYAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-385-0675
Mailing Address - Street 1:PO BOX 27206
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-0206
Mailing Address - Country:US
Mailing Address - Phone:213-385-0675
Mailing Address - Fax:213-365-6429
Practice Address - Street 1:540 N CENTRAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3350
Practice Address - Country:US
Practice Address - Phone:818-244-2224
Practice Address - Fax:818-244-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100597208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA100597OtherSTATE LICENSE