Provider Demographics
NPI:1013276872
Name:KHACHATRYAN, TIGRAN
Entity Type:Individual
Prefix:
First Name:TIGRAN
Middle Name:
Last Name:KHACHATRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1008
Mailing Address - Country:US
Mailing Address - Phone:818-243-9600
Mailing Address - Fax:
Practice Address - Street 1:660 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1008
Practice Address - Country:US
Practice Address - Phone:818-243-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127412207R00000X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty