Provider Demographics
NPI:1528276078
Name:MICHAEL P. KOUMJIAN, MD, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MICHAEL P. KOUMJIAN, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:KOUMJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-466-5700
Mailing Address - Street 1:5525 GROSSMONT CENTER DRIVE , SUITE 609
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-466-5700
Mailing Address - Fax:619-460-8975
Practice Address - Street 1:5525 GROSSMONT CENTER DR STE 609
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:619-466-5700
Practice Address - Fax:619-460-8975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066270Medicaid
CAGR0066270Medicaid
W13831Medicare ID - Type Unspecified