Provider Demographics
NPI:1366403321
Name:KOUMJIAN, MICHAEL PETER (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PETER
Last Name:KOUMJIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5525 GROSSMONT CENTER DR STE 609
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3009
Mailing Address - Country:US
Mailing Address - Phone:619-466-5700
Mailing Address - Fax:619-460-8975
Practice Address - Street 1:5525 GROSSMONT CENTER DR
Practice Address - Street 2:STE 609
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-466-5700
Practice Address - Fax:619-460-8975
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37886208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066270Medicaid
A91943Medicare UPIN
CAGR0066270Medicaid