Provider Demographics
NPI:1265010920
Name:AZRENKASSIAN, SETRAK MANOUK MISSAK
Entity type:Individual
Prefix:
First Name:SETRAK MANOUK
Middle Name:MISSAK
Last Name:AZRENKASSIAN
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 1:8608 FOOTHILL BLVD APT 218
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-1976
Mailing Address - Country:US
Mailing Address - Phone:818-439-0941
Mailing Address - Fax:
Practice Address - Street 1:215 W JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1847
Practice Address - Country:US
Practice Address - Phone:805-497-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA193958207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine