Provider Demographics
NPI:1679899033
Name:BAGHDASSARIAN, ANI BERGMAN
Entity type:Individual
Prefix:
First Name:ANI
Middle Name:BERGMAN
Last Name:BAGHDASSARIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 SUPERIOR AVE
Mailing Address - Street 2:STE 200B
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3663
Mailing Address - Country:US
Mailing Address - Phone:949-791-3001
Mailing Address - Fax:949-791-3096
Practice Address - Street 1:510 SUPERIOR AVE
Practice Address - Street 2:STE 200B
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3663
Practice Address - Country:US
Practice Address - Phone:949-791-3001
Practice Address - Fax:949-791-3096
Is Sole Proprietor?:No
Enumeration Date:2010-04-10
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA121527207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HK028ZMedicare PIN