Provider Demographics
NPI:1689980914
Name:STEPHAN GRIGORIAN MD INC
Entity Type:Organization
Organization Name:STEPHAN GRIGORIAN MD INC
Other - Org Name:GLENPATH DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GRIGORIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-507-1200
Mailing Address - Street 1:800 S CENTRAL AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4370
Mailing Address - Country:US
Mailing Address - Phone:818-507-1200
Mailing Address - Fax:818-507-1200
Practice Address - Street 1:800 S CENTRAL AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4370
Practice Address - Country:US
Practice Address - Phone:818-507-1200
Practice Address - Fax:818-507-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88170207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEA818AMedicare PIN