Provider Demographics
NPI:1053672006
Name:GHALILI, MAZIAR MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:MAZIAR
Middle Name:MARK
Last Name:GHALILI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:GHALILI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2101 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1125
Mailing Address - Country:US
Mailing Address - Phone:702-671-2341
Mailing Address - Fax:
Practice Address - Street 1:2101 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1125
Practice Address - Country:US
Practice Address - Phone:702-671-2341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL0884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine