Provider Demographics
NPI:1386774255
Name:BARDAKJIAN, VATCHE B (MD)
Entity type:Individual
Prefix:
First Name:VATCHE
Middle Name:B
Last Name:BARDAKJIAN
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 1:1500 S CENTRAL AVE
Mailing Address - Street 2:SUITE 126
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
Practice Address - Street 2:SUITE 126
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
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA459552086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA459551Medicaid
A56854Medicare UPIN
CAOOA459551Medicaid