Provider Demographics
NPI:1710915038
Name:DERBOGHOSSIANS, SHAHIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHIN
Middle Name:
Last Name:DERBOGHOSSIANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 S LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1025
Mailing Address - Country:US
Mailing Address - Phone:818-507-4340
Mailing Address - Fax:818-507-4308
Practice Address - Street 1:116 S LOUISE ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-507-4340
Practice Address - Fax:818-507-4308
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42661208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A426610Medicaid
CAB50498Medicare UPIN
CAA42661BMedicare ID - Type Unspecified