Provider Demographics
NPI:1376980078
Name:MIRMIRAN, AHMADREZA (MD)
Entity Type:Individual
Prefix:DR
First Name:AHMADREZA
Middle Name:
Last Name:MIRMIRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ADAM
Other - Middle Name:
Other - Last Name:MIRMIRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5123 GARDEN GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4340
Mailing Address - Country:US
Mailing Address - Phone:818-983-3131
Mailing Address - Fax:
Practice Address - Street 1:5123 GARDEN GROVE AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4340
Practice Address - Country:US
Practice Address - Phone:818-983-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30995207RH0002X
KS0439448207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine