Provider Demographics
NPI:1407526270
Name:MARYAMPOURSARTIPMD INC.
Entity Type:Organization
Organization Name:MARYAMPOURSARTIPMD INC.
Other - Org Name:80/20 QUANTUM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERNAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:POURSARTIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-575-6669
Mailing Address - Street 1:258 WHITE CAP LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1088
Mailing Address - Country:US
Mailing Address - Phone:917-575-6669
Mailing Address - Fax:
Practice Address - Street 1:665 CAMINO DE LOS MARES STE 305
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2841
Practice Address - Country:US
Practice Address - Phone:949-371-9259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty