Basic Information
| Provider Information | |||||||||
| NPI: | 1902828056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEVOSIAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10429 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926580429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494171812 | ||||||||
| FaxNumber: | 9494171803 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629332000 | ||||||||
| FaxNumber: | 5629331245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207L00000X | 20A9026 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 020A90260 | 01 | CA | BLUE SHIELD ID # | OTHER | P00260571 | 01 | CA | RAILROAD MEDICARE ID # | OTHER | 00AX90260 | 05 | CA | MEDICAID | 00AX90260385 | 01 | CA | CALOPTIMA ID # | OTHER |