Provider Demographics
NPI:1790817039
Name:HERACH YADEGARIAN, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HERACH YADEGARIAN, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERACH
Authorized Official - Middle Name:
Authorized Official - Last Name:YADEGARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-240-8767
Mailing Address - Street 1:800 S. CENTRAL AVE.
Mailing Address - Street 2:SUITE 308
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4644
Mailing Address - Country:US
Mailing Address - Phone:818-240-8767
Mailing Address - Fax:818-502-0254
Practice Address - Street 1:800 S. CENTRAL AVE.
Practice Address - Street 2:SUITE 308
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4644
Practice Address - Country:US
Practice Address - Phone:818-240-8767
Practice Address - Fax:818-502-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty