Provider Demographics
NPI:1962562611
Name:YAGHOUBIAN, VAZGEN EDWARD (PHD)
Entity type:Individual
Prefix:
First Name:VAZGEN
Middle Name:EDWARD
Last Name:YAGHOUBIAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SAINTSBURY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-4025
Mailing Address - Country:US
Mailing Address - Phone:818-288-7155
Mailing Address - Fax:714-829-3011
Practice Address - Street 1:2020 EAST 1ST STREET
Practice Address - Street 2:STE 103
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-2435
Practice Address - Country:US
Practice Address - Phone:818-288-7155
Practice Address - Fax:714-829-3011
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL509248133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P60389Medicare UPIN
CAMNT509248Medicare ID - Type Unspecified