Provider Demographics
NPI:1881748077
Name:DERBOGHOSSIAN, HAIG
Entity type:Individual
Prefix:
First Name:HAIG
Middle Name:
Last Name:DERBOGHOSSIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3204
Mailing Address - Country:US
Mailing Address - Phone:559-271-1186
Mailing Address - Fax:559-271-8041
Practice Address - Street 1:3443 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3204
Practice Address - Country:US
Practice Address - Phone:559-271-1186
Practice Address - Fax:559-271-8041
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB32197390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program