Provider Demographics
NPI:1114381753
Name:HOSSEINI FARAHABADI, MARYAM (MD, MS)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:HOSSEINI FARAHABADI
Suffix:
Gender:F
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S MANCHESTER AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3226
Mailing Address - Country:US
Mailing Address - Phone:714-456-6808
Mailing Address - Fax:
Practice Address - Street 1:200 S MANCHESTER AVE STE 206
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3226
Practice Address - Country:US
Practice Address - Phone:714-456-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-10
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-08112084V0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology