Provider Demographics
NPI:1457712309
Name:DERDERYAN MEDICAL GROUP INC.
Entity type:Organization
Organization Name:DERDERYAN MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:VARUZHAN
Authorized Official - Last Name:DERDERYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-552-1547
Mailing Address - Street 1:4955 VAN NUYS BLVD STE 308
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD STE 308
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1811
Practice Address - Country:US
Practice Address - Phone:646-552-1547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty