Provider Demographics
NPI:1790218550
Name:VARDERESSIAN, NOUBAR (DPM)
Entity Type:Individual
Prefix:DR
First Name:NOUBAR
Middle Name:
Last Name:VARDERESSIAN
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 1:1122 N COLUMBUS AVE
Mailing Address - Street 2:APT. 2
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3241
Mailing Address - Country:US
Mailing Address - Phone:818-606-6740
Mailing Address - Fax:
Practice Address - Street 1:1122 N COLUMBUS AVE
Practice Address - Street 2:APT. 2
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3241
Practice Address - Country:US
Practice Address - Phone:818-606-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006823213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery