Provider Demographics
NPI:1689141483
Name:DANIELIAN, VADIM
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:DANIELIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9439 VIA VENEZIA
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-1244
Mailing Address - Country:US
Mailing Address - Phone:323-821-7772
Mailing Address - Fax:
Practice Address - Street 1:9439 VIA VENEZIA
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-1244
Practice Address - Country:US
Practice Address - Phone:323-821-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily