Provider Demographics
NPI:1467095539
Name:MIRDAMADI, PEDI
Entity Type:Individual
Prefix:
First Name:PEDI
Middle Name:
Last Name:MIRDAMADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11228 VISTA SORRENTO PKWY UNIT I300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-7622
Mailing Address - Country:US
Mailing Address - Phone:858-253-1222
Mailing Address - Fax:
Practice Address - Street 1:6919 LA JOLLA BLVD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5427
Practice Address - Country:US
Practice Address - Phone:858-459-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND1106175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath