Provider Demographics
NPI:1811207483
Name:SHAHIN DERBOGHOSSIANS MD INC
Entity type:Organization
Organization Name:SHAHIN DERBOGHOSSIANS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERBOGHOSSIANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-507-4340
Mailing Address - Street 1:1030 S GLENDALE
Mailing Address - Street 2:301
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-507-4340
Mailing Address - Fax:818-507-4348
Practice Address - Street 1:1030 S GLENDALE
Practice Address - Street 2:301
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-507-4340
Practice Address - Fax:818-507-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42661208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A42661OtherMEDICAL LICENSE
CA00A426610Medicaid
CA00A426610Medicaid