Provider Demographics
NPI:1548521156
Name:GLENDALE PLASTIC AND RECONSTRUCTIVE SURGERY INC.
Entity type:Organization
Organization Name:GLENDALE PLASTIC AND RECONSTRUCTIVE SURGERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VATCHE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BARDAKJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-247-4894
Mailing Address - Street 1:1500 S. CENTRAL AVE. #126
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204
Mailing Address - Country:US
Mailing Address - Phone:818-247-4894
Mailing Address - Fax:818-247-4163
Practice Address - Street 1:1500 S. CENTRAL AVE. #126
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204
Practice Address - Country:US
Practice Address - Phone:818-247-4894
Practice Address - Fax:818-247-4163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45955208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA56854Medicare UPIN