Provider Demographics
NPI:1174861264
Name:GOODARZI, MARY (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GOODARZI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SWEET BAY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603
Mailing Address - Country:US
Mailing Address - Phone:949-412-9424
Mailing Address - Fax:
Practice Address - Street 1:1339 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2033
Practice Address - Country:US
Practice Address - Phone:310-829-8921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program