Provider Demographics
NPI:1376515403
Name:MOINFAR, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOINFAR
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 1:34213 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2875
Mailing Address - Country:US
Mailing Address - Phone:952-240-2827
Mailing Address - Fax:949-248-4587
Practice Address - Street 1:34213 PACIFIC COAST HWY
Practice Address - Street 2:SUITE A
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2875
Practice Address - Country:US
Practice Address - Phone:952-240-2827
Practice Address - Fax:949-248-4587
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92449207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA92449AMedicare UPIN
CAI45353Medicare UPIN