Provider Demographics
NPI:1457738460
Name:ANTOSSYAN, MERI (DO)
Entity type:Individual
Prefix:DR
First Name:MERI
Middle Name:
Last Name:ANTOSSYAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:ANTOSSYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:544 N GLENDALE AVE STE B
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3311
Practice Address - Country:US
Practice Address - Phone:747-212-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13819207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB262588Medicare PIN