Individual
HAKOB GRIGOR DAVTYAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
401 E HIGHLAND AVE, SUITE 251, SAN BERNARDINO, CA 92404-3803
(909) 881-1614
(909) 881-2711
Mailing address
401 E HIGHLAND AVE, SUITE 251, SAN BERNARDINO, CA 92404-3803
(909) 881-1614
(909) 881-2711
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
G54367
CA
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
031902
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G543670
—
CA
01
—
00G543671
MEDICARE INDIVIDUAL PTAN
—
01
—
031902
LICENSE
GA
01
—
G54367
LICENSE
CA
01
—
ZZZ07161Z
MEDICARE GROUP PTAN
—
Enumeration date
07/05/2006
Last updated
07/12/2016
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