Provider Demographics
NPI:1699902288
Name:MARDIROSIAN, ANITA SHWARSH ISRAEL (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:SHWARSH ISRAEL
Last Name:MARDIROSIAN
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-815-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00526208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015499Medicaid
SCQ005AEMedicaid
WV3190998OtherCIGNA
OH000000277545OtherOH UNISON
KY7100092210Medicaid
NC1699902288Medicaid
OH2969364Medicaid
WV613154600OtherFEDERAL BLACK LUNG/FECA
KY7100092210Medicaid
NC1699902288Medicaid
WVP00768206Medicare PIN