Provider Demographics
NPI:1093826539
Name:AMIRI, MARIAM SHANAZ (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:SHANAZ
Last Name:AMIRI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1059
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1059
Mailing Address - Country:US
Mailing Address - Phone:909-796-3707
Mailing Address - Fax:909-796-3709
Practice Address - Street 1:11332 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3854
Practice Address - Country:US
Practice Address - Phone:909-796-3707
Practice Address - Fax:909-796-3709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4049213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40490Medicaid
CAU57557Medicare UPIN
CA000E40490Medicare ID - Type Unspecified
CA1277260001Medicare NSC