Provider Demographics
NPI:1487738399
Name:KHACHATRIAN, MARINA (MD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:KHACHATRIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12643 SHERMAN WAY
Mailing Address - Street 2:UNIT I
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605
Mailing Address - Country:US
Mailing Address - Phone:818-759-0095
Mailing Address - Fax:818-759-0049
Practice Address - Street 1:12643 SHERMAN WAY
Practice Address - Street 2:UNIT I
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605
Practice Address - Country:US
Practice Address - Phone:818-759-0095
Practice Address - Fax:818-759-0049
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA693780Medicaid
CAOOA693780Medicaid
H01077Medicare UPIN