Provider Demographics
NPI:1992726012
Name:BAGHDASERIANI, LYDIA
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:BAGHDASERIANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E PROVIDENCIA AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2756
Mailing Address - Country:US
Mailing Address - Phone:818-662-0208
Mailing Address - Fax:661-822-2049
Practice Address - Street 1:310 E PROVIDENCIA AVE APT 106
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-2756
Practice Address - Country:US
Practice Address - Phone:818-662-0208
Practice Address - Fax:661-822-2049
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0247760OtherBLUE SHIELD
CAU88327Medicare UPIN
CADC24776Medicare ID - Type UnspecifiedMEDICARE