Provider Demographics
NPI:1710177845
Name:PANOSSIAN, ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:PANOSSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDRE
Other - Middle Name:A
Other - Last Name:PANOSSIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:39 CONGRESS ST STE 402
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3024
Mailing Address - Country:US
Mailing Address - Phone:800-958-3778
Mailing Address - Fax:800-958-3778
Practice Address - Street 1:39 CONGRESS ST STE 402
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3024
Practice Address - Country:US
Practice Address - Phone:800-958-3778
Practice Address - Fax:800-958-3778
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76052208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A760520OtherBLUE SHIELD #
CA1710177845Medicaid
CA00A760520OtherBLUE SHIELD #