Provider Demographics
NPI:1629024393
Name:AVAKYAN, RAFAEL (MD)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:AVAKYAN
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 1:1300 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2506
Mailing Address - Country:US
Mailing Address - Phone:818-247-7447
Mailing Address - Fax:818-247-1484
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-4770
Practice Address - Fax:818-502-4714
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84288Medicare ID - Type Unspecified
CAH99386Medicare UPIN