Provider Demographics
NPI:1225179732
Name:MIZRAHI, MARYAM Y (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARYAM
Middle Name:Y
Last Name:MIZRAHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 PHYSICIANS LN
Mailing Address - Street 2:SUITE 132
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3940
Mailing Address - Country:US
Mailing Address - Phone:301-610-5080
Mailing Address - Fax:301-610-5065
Practice Address - Street 1:14800 PHYSICIANS LN
Practice Address - Street 2:SUITE 132
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3940
Practice Address - Country:US
Practice Address - Phone:301-610-5080
Practice Address - Fax:301-610-5065
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034505207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD904002100Medicaid
MD904002100Medicaid
MDG02040M01Medicare PIN