Provider Demographics
NPI:1225298110
Name:POURSARTIP, MARYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:POURSARTIP
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 1:111 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5813
Mailing Address - Country:US
Mailing Address - Phone:917-575-6669
Mailing Address - Fax:
Practice Address - Street 1:66675 PIERSON BLVD
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-3737
Practice Address - Country:US
Practice Address - Phone:760-676-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine