Provider Demographics
NPI:1366600355
Name:NAZARETH E DARAKJIAN
Entity type:Organization
Organization Name:NAZARETH E DARAKJIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAZARETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:DARAKJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-794-2356
Mailing Address - Street 1:2595 E WASHINGTON BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1409
Mailing Address - Country:US
Mailing Address - Phone:626-794-2356
Mailing Address - Fax:
Practice Address - Street 1:2595 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1409
Practice Address - Country:US
Practice Address - Phone:626-794-2356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAZARETH E DARAKJIAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 44736332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G447360Medicaid
CA00G447360Medicaid
CAG44736Medicare PIN