Provider Demographics
NPI:1710173489
Name:GLENDALE FOOT & ANKLE PODIATRY CENTER, INC.
Entity Type:Organization
Organization Name:GLENDALE FOOT & ANKLE PODIATRY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMOZ
Authorized Official - Middle Name:B
Authorized Official - Last Name:AYVAZIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-242-4426
Mailing Address - Street 1:110 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1312
Mailing Address - Country:US
Mailing Address - Phone:818-242-4426
Mailing Address - Fax:818-242-4409
Practice Address - Street 1:110 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1312
Practice Address - Country:US
Practice Address - Phone:818-242-4426
Practice Address - Fax:818-242-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3761213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ60226ZOtherBLUE SHIELD
CA480027586OtherRAILROAD MEDICARE
CA000E37610Medicaid
CA05D0856782OtherCLIA
CA4320950001Medicare NSC
CAW14674Medicare PIN
CA05D0856782OtherCLIA