Provider Demographics
NPI:1780631523
Name:MORADIAN, MARTIN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:MORADIAN
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 1:1500 S CENTRAL AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2563
Mailing Address - Country:US
Mailing Address - Phone:818-243-0400
Mailing Address - Fax:818-507-9902
Practice Address - Street 1:1500 S CENTRAL AVE
Practice Address - Street 2:STE 101
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2563
Practice Address - Country:US
Practice Address - Phone:818-243-0400
Practice Address - Fax:818-507-9902
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4513A213E00000X
CAE4513213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E45130Medicaid
CAU98539Medicare UPIN
CAE4513BMedicare ID - Type Unspecified
CAE4513AMedicare ID - Type Unspecified
CA6004380001Medicare NSC
CA000E45130Medicaid