Provider Demographics
NPI:1083739882
Name:MARDIROS, MARAL MELISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARAL
Middle Name:MELISSA
Last Name:MARDIROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:MARAL
Other - Last Name:MARDIROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5601 DE SOTO AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6701
Mailing Address - Country:US
Mailing Address - Phone:818-719-2922
Mailing Address - Fax:
Practice Address - Street 1:5601 DE SOTO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6701
Practice Address - Country:US
Practice Address - Phone:818-719-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83426207UN0902X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA128112Medicare UPIN