Basic Information
| Provider Information | |||||||||
| NPI: | 1902418700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DJAVAHERIAN MEDICAL PRACTICE PLLC | ||||||||
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| OtherOrganizationName: | CARBON HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 PACIFIC AVE # 101 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941112009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152002133 | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 HAVEMEYER ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112113340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152002133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2020 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | MILES | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7758134777 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.