Provider Demographics
NPI:1598096067
Name:GHAVAMI-MAIBODI, MARYAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:M
Last Name:GHAVAMI-MAIBODI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:GHAVAMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7900
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-24
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116322208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics