Basic Information
| Provider Information | |||||||||
| NPI: | 1831608165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIROSSIAN | ||||||||
| FirstName: | TALLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 S GLENDALE AVE | ||||||||
| Address2: | STE 404 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912052866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 8554206361 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 S GLENDALE AVE STE 404 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912052866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182409911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2017 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6978 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 55145 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | 6978 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 55145 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RG0300X | 55145 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.