Provider Demographics
NPI:1942263322
Name:BOGHOSSIAN, GERARD H (DPM)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:H
Last Name:BOGHOSSIAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42135 10TH ST W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7095
Mailing Address - Country:US
Mailing Address - Phone:661-726-5005
Mailing Address - Fax:661-726-5377
Practice Address - Street 1:42135 10TH ST W
Practice Address - Street 2:SUITE 101
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7095
Practice Address - Country:US
Practice Address - Phone:661-726-5005
Practice Address - Fax:661-726-5377
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4323213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00E43231OtherMEDI-CAL
CA00E43231OtherMEDI-CAL