Provider Demographics
NPI:1790812162
Name:PETROSSIAN, MELITA TALENE (MD)
Entity Type:Individual
Prefix:
First Name:MELITA
Middle Name:TALENE
Last Name:PETROSSIAN
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2312
Mailing Address - Country:US
Mailing Address - Phone:310-582-7433
Mailing Address - Fax:310-582-7495
Practice Address - Street 1:1301 20TH ST STE 150
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-582-7433
Practice Address - Fax:310-582-7495
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1209542084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790812162Medicaid
CAGH095ZMedicare PIN