Provider Demographics
NPI:1689145807
Name:AYVAZYAN, SALINE
Entity Type:Individual
Prefix:
First Name:SALINE
Middle Name:
Last Name:AYVAZYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10128 HILLHAVEN AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-3662
Mailing Address - Country:US
Mailing Address - Phone:818-621-3413
Mailing Address - Fax:
Practice Address - Street 1:3600 N VERDUGO RD STE 300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1258
Practice Address - Country:US
Practice Address - Phone:818-249-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty