Provider Demographics
NPI:1760564272
Name:AYVAZIAN, HERMOZ B (DPM)
Entity Type:Individual
Prefix:DR
First Name:HERMOZ
Middle Name:B
Last Name:AYVAZIAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3761213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E37610Medicaid
CAE3761OtherBLUE CROSS
CA4320950001OtherDMERC ID
CA05D0856782OtherCLIA
CA200858800OtherUS DEPT OF LABOR
CAZZZ60226ZOtherBLUE SHIELD
CA480027586OtherRAILROAD MEDICARE
CA954745477OtherTAX ID
CA480027586OtherRAILROAD MEDICARE
CA05D0856782OtherCLIA