Provider Demographics
NPI:1346773934
Name:GHIASSI, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:GHIASSI
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 1:3 PARK CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-8341
Mailing Address - Country:US
Mailing Address - Phone:916-454-6191
Mailing Address - Fax:
Practice Address - Street 1:3 PARK CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-8340
Practice Address - Country:US
Practice Address - Phone:916-454-4861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0065808207WX0107X
CAA184813207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist