Provider Demographics
NPI:1972023778
Name:VARDANYAN, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:VARDANYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD STE 502
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1817
Mailing Address - Country:US
Mailing Address - Phone:818-325-0200
Mailing Address - Fax:818-325-0210
Practice Address - Street 1:4955 VAN NUYS BLVD STE 502
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1817
Practice Address - Country:US
Practice Address - Phone:818-325-0200
Practice Address - Fax:818-325-0210
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA272350207R00000X
CA169373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine