Provider Demographics
NPI:1972614493
Name:KAYICHIAN, DESPINA GHABY (MD)
Entity type:Individual
Prefix:
First Name:DESPINA
Middle Name:GHABY
Last Name:KAYICHIAN
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 1:1500 S CENTRAL AVE
Mailing Address - Street 2:SUITE #221
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2530
Mailing Address - Country:US
Mailing Address - Phone:818-500-4055
Mailing Address - Fax:818-500-4065
Practice Address - Street 1:604 ROSE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:310-392-7875
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52950174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A529500Medicaid
WA52950BMedicare ID - Type Unspecified
CA00A529500Medicaid