Provider Demographics
NPI:1255359840
Name:KLTCHIAN, MISSAK (MD)
Entity type:Individual
Prefix:
First Name:MISSAK
Middle Name:
Last Name:KLTCHIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 HOLLYWOOD BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5455
Mailing Address - Country:US
Mailing Address - Phone:323-661-4500
Mailing Address - Fax:323-661-3260
Practice Address - Street 1:4645 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5455
Practice Address - Country:US
Practice Address - Phone:323-661-4500
Practice Address - Fax:323-661-3260
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A523681Medicaid
F73039Medicare UPIN
A52368Medicare ID - Type Unspecified