Provider Demographics
NPI:1932695079
Name:MISSAK KLTCHIAN MD INC.
Entity Type:Organization
Organization Name:MISSAK KLTCHIAN MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MISSAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KLTCHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-661-4500
Mailing Address - Street 1:4645 HOLLYWOOD BLVD STE 2/4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5455
Mailing Address - Country:US
Mailing Address - Phone:323-661-4500
Mailing Address - Fax:323-661-3260
Practice Address - Street 1:4645 HOLLYWOOD BLVD STE 2/4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5455
Practice Address - Country:US
Practice Address - Phone:323-661-4500
Practice Address - Fax:323-661-3260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A52368Medicaid
CA1578901237OtherMEDICARE
CA1255359840OtherMEDICARE