Provider Demographics
NPI:1841303849
Name:BOGHOSSIAN, FREDERICK A (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:A
Last Name:BOGHOSSIAN
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 1:1560 E CHEVY CHASE DR
Mailing Address - Street 2:SUITE # 320
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-241-0300
Mailing Address - Fax:818-241-0333
Practice Address - Street 1:1560 E CHEVY CHASE DR
Practice Address - Street 2:SUITE # 320
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-241-0300
Practice Address - Fax:818-241-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA648780207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16634Medicare ID - Type UnspecifiedGROUP ID #