Provider Demographics
NPI:1255465506
Name:MUTAFYAN, GEVORG ARUTYUNAVICH (MD)
Entity type:Individual
Prefix:
First Name:GEVORG
Middle Name:ARUTYUNAVICH
Last Name:MUTAFYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1510 S CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2588
Mailing Address - Country:US
Mailing Address - Phone:818-247-2000
Mailing Address - Fax:818-247-2121
Practice Address - Street 1:1510 S CENTRAL AVE STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2588
Practice Address - Country:US
Practice Address - Phone:818-247-2000
Practice Address - Fax:818-247-2121
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2006-00669208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2065975Medicare PIN