Provider Demographics
NPI:1164876439
Name:EMAMI, MARYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:EMAMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAHEREH
Other - Middle Name:
Other - Last Name:EMAMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:3769 CROSSINGS DR STE B
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7270
Mailing Address - Country:US
Mailing Address - Phone:928-888-9750
Mailing Address - Fax:928-888-9790
Practice Address - Street 1:3769 CROSSINGS DR STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7270
Practice Address - Country:US
Practice Address - Phone:480-808-8281
Practice Address - Fax:330-624-9294
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266087207Q00000X
DCMD047334207Q00000X
AZ58435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ559428Medicaid