Provider Demographics
NPI:1720050032
Name:KHUDATYAN, HRACH (MD)
Entity type:Individual
Prefix:
First Name:HRACH
Middle Name:
Last Name:KHUDATYAN
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 1:134 N GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4451
Mailing Address - Country:US
Mailing Address - Phone:818-662-8858
Mailing Address - Fax:818-662-8987
Practice Address - Street 1:134 N GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4451
Practice Address - Country:US
Practice Address - Phone:818-662-8858
Practice Address - Fax:818-662-8987
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-09-15
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CAA60871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A608711Medicaid
CAA60871Medicare ID - Type Unspecified
CA00A608711Medicaid