Provider Demographics
NPI:1821009812
Name:DEIRMENJIAN, JOHN MGRDITCH (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MGRDITCH
Last Name:DEIRMENJIAN
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 1:333 W. BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802
Mailing Address - Country:US
Mailing Address - Phone:310-428-3234
Mailing Address - Fax:562-901-0501
Practice Address - Street 1:333 W BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4437
Practice Address - Country:US
Practice Address - Phone:310-428-3234
Practice Address - Fax:562-901-0501
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG770092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G770090Medicaid
CAG23526Medicare UPIN
CAWG77009BMedicare PIN