Provider Demographics
NPI:1013070929
Name:OVSEPIAN, MARYETTA (MD PHD)
Entity Type:Individual
Prefix:
First Name:MARYETTA
Middle Name:
Last Name:OVSEPIAN
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10125 BROMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352
Mailing Address - Country:US
Mailing Address - Phone:818-252-5686
Mailing Address - Fax:818-252-7187
Practice Address - Street 1:L4445 OLIVE VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1495
Practice Address - Country:US
Practice Address - Phone:818-364-4350
Practice Address - Fax:818-364-4775
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69455207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H50633Medicare UPIN