Provider Demographics
NPI:1215118708
Name:ANTOSSYAN, LEVON (MD)
Entity type:Individual
Prefix:DR
First Name:LEVON
Middle Name:
Last Name:ANTOSSYAN
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 1:1204 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:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0053324208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A533241Medicaid
F88086Medicare PIN