Provider Demographics
NPI:1902418700
Name:DJAVAHERIAN MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:DJAVAHERIAN MEDICAL PRACTICE PLLC
Other - Org Name:CARBON HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEAD OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-813-4777
Mailing Address - Street 1:55 PACIFIC AVE # 101
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-2009
Mailing Address - Country:US
Mailing Address - Phone:415-200-2133
Mailing Address - Fax:
Practice Address - Street 1:90 HAVEMEYER ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-3340
Practice Address - Country:US
Practice Address - Phone:415-200-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care