Provider Demographics
NPI:1285653196
Name:MORTEZAIEFARD, MARYAM (DO)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MORTEZAIEFARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22110 ROSCOE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3845
Mailing Address - Country:US
Mailing Address - Phone:818-888-8042
Mailing Address - Fax:
Practice Address - Street 1:22110 ROSCOE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91304-3845
Practice Address - Country:US
Practice Address - Phone:818-888-8042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine