NPIMap

Organization Active NPI

Derderyan Medical Group Inc.

  • Internal Medicine Physician
  • Sherman Oaks, CA
National Provider Identifier
1457712309
Registry record updated Feb 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
DERDERYAN MEDICAL GROUP INC.
Practice address
4955 Van Nuys Blvd Ste 308
Sherman Oaks, CA 91403-1811
Phone
(646) 552-1547
NPI assigned
Mar 18, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 7, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Edmond Varuzhan Derderyan, M.D
Title
President/Owner
Phone
(646) 552-1547

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

4955 Van Nuys Blvd Ste 308
Sherman Oaks, CA 91403-1811

Mailing address

4955 Van Nuys Blvd Ste 308
Sherman Oaks, CA 91403-1811

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160425002354 CA Part B Supplier - Clinic/Group Practice 8325347396 Receives reassigned benefits from 14 practitioners
Practice locations: Valley Village, CA; Woodland Hills, CA; Van Nuys, CA; Studio City, CA; Sherman Oaks, CA

National Provider Directory

National Provider Directory

Locations

4610 Coldwater Canyon Ave
Studio City, CA 91604
Phone (818) 387-6114

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1458259200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612656000000",
    "number": "1457712309",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4955 VAN NUYS BLVD STE 308",
            "city": "SHERMAN OAKS",
            "state": "CA",
            "postal_code": "914031811"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4955 VAN NUYS BLVD STE 308",
            "city": "SHERMAN OAKS",
            "state": "CA",
            "postal_code": "914031811",
            "telephone_number": "646-552-1547"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERDERYAN MEDICAL GROUP INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-18",
        "last_updated": "2021-02-07",
        "certification_date": "2021-02-07",
        "status": "A",
        "authorized_official_last_name": "DERDERYAN",
        "authorized_official_first_name": "EDMOND",
        "authorized_official_middle_name": "VARUZHAN",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "646-552-1547",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sherman Oaks, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.