Provider Demographics
NPI:1790966760
Name:SHADAREVIAN, MARCAR
Entity Type:Individual
Prefix:
First Name:MARCAR
Middle Name:
Last Name:SHADAREVIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 HONOLULU AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91214
Mailing Address - Country:US
Mailing Address - Phone:818-244-5497
Mailing Address - Fax:818-244-2822
Practice Address - Street 1:2837 HONOLULU AVE.
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91214
Practice Address - Country:US
Practice Address - Phone:818-244-5497
Practice Address - Fax:818-244-2822
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02448FMedicaid
CADME02448FMedicaid