Provider Demographics
NPI:1922063759
Name:TAVITIAN, ARA (MD)
Entity Type:Individual
Prefix:MR
First Name:ARA
Middle Name:
Last Name:TAVITIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S CHEVY CHASE DRIVE
Mailing Address - Street 2:#30
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-265-2232
Mailing Address - Fax:818-450-0438
Practice Address - Street 1:801 S CHEVY CHASE DRIVE
Practice Address - Street 2:#30
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-265-2232
Practice Address - Fax:818-450-0438
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63489207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE78399Medicare UPIN