Provider Demographics
NPI:1083254387
Name:ESFAHANI ZAREH, MARYAM
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:ESFAHANI ZAREH
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 1:18516 GINGERBREAD LN
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-3534
Mailing Address - Country:US
Mailing Address - Phone:240-380-6507
Mailing Address - Fax:
Practice Address - Street 1:18516 GINGERBREAD LN
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-3534
Practice Address - Country:US
Practice Address - Phone:240-380-6507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007431363A00000X
VA0110007101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant