Provider Demographics
NPI:1922074350
Name:BAKTANIAN, EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:BAKTANIAN
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:PO BOX 9240
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91226-0240
Mailing Address - Country:US
Mailing Address - Phone:818-653-1970
Mailing Address - Fax:
Practice Address - Street 1:1030 S GLENDALE AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-5612
Practice Address - Country:US
Practice Address - Phone:818-653-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-25
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85580207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABV002AMedicare PIN
CABV002YMedicare PIN