Provider Demographics
NPI:1023029162
Name:ST JOHN, MAIE ABDUL-RAHMAN (MD)
Entity Type:Individual
Prefix:
First Name:MAIE
Middle Name:ABDUL-RAHMAN
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-206-6688
Mailing Address - Fax:310-206-4105
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#550
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-206-6688
Practice Address - Fax:310-206-4105
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75058207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A750580Medicaid
CA00A750580Medicaid
CACK385ZMedicare PIN