Provider Demographics
NPI:1750477279
Name:KHATCHATOURIAN, HENRIK (MD)
Entity Type:Individual
Prefix:
First Name:HENRIK
Middle Name:
Last Name:KHATCHATOURIAN
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 1:445 W. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204
Mailing Address - Country:US
Mailing Address - Phone:818-241-2103
Mailing Address - Fax:818-241-1090
Practice Address - Street 1:445 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204
Practice Address - Country:US
Practice Address - Phone:818-241-2103
Practice Address - Fax:818-241-1090
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A556230Medicaid
CAG26460Medicare UPIN
CAWA55623AMedicare PIN