Provider Demographics
NPI:1548303803
Name:DERAVEDISSIAN, HARRY (DC)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:
Last Name:DERAVEDISSIAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 S BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2902
Mailing Address - Country:US
Mailing Address - Phone:818-543-5900
Mailing Address - Fax:818-543-5902
Practice Address - Street 1:1829 S BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2902
Practice Address - Country:US
Practice Address - Phone:818-543-5900
Practice Address - Fax:818-543-5902
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0219420Medicaid
CAU39306Medicare UPIN
CADC0219420Medicaid