Provider Demographics
NPI:1508536343
Name:MIRZAEI, MARYAM (OD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MIRZAEI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6285 E SPRING ST # 290
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-4020
Mailing Address - Country:US
Mailing Address - Phone:562-799-2020
Mailing Address - Fax:
Practice Address - Street 1:2925 PALO VERDE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1552
Practice Address - Country:US
Practice Address - Phone:562-799-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X, 390200000X
CA35032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program