Provider Demographics
NPI:1932150224
Name:LEVON ANTOSSYAN INC
Entity Type:Organization
Organization Name:LEVON ANTOSSYAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOSSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-551-0001
Mailing Address - Street 1:1204 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2504
Mailing Address - Country:US
Mailing Address - Phone:818-551-0001
Mailing Address - Fax:
Practice Address - Street 1:1204 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2504
Practice Address - Country:US
Practice Address - Phone:818-551-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053324261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A533241Medicaid
CAF88086Medicare UPIN
CAW21785Medicare PIN