Provider Demographics
NPI:1952496663
Name:KEVORKIAN, VICTOR AVEDIS (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:AVEDIS
Last Name:KEVORKIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14111 VAN NESS AVE
Mailing Address - Street 2:#4
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2944
Mailing Address - Country:US
Mailing Address - Phone:310-516-9152
Mailing Address - Fax:310-329-2121
Practice Address - Street 1:14111 VAN NESS AVE
Practice Address - Street 2:#4
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2944
Practice Address - Country:US
Practice Address - Phone:310-516-9152
Practice Address - Fax:310-329-2121
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34034174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A340340Medicaid
CA95-3677784OtherTAX IDENTIFICATION
CA95-3677784OtherTAX IDENTIFICATION