Basic Information
| Provider Information | |||||||||
| NPI: | 1821455452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETROSSIAN | ||||||||
| FirstName: | EDMOND | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9602 | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913469602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188375559 | ||||||||
| FaxNumber: | 8187924793 | ||||||||
| Practice Location | |||||||||
| Address1: | 11333 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776343196 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A15290 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.