Provider Demographics
NPI:1649378928
Name:FORTANI, MARYAM
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:FORTANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4361 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6611
Mailing Address - Country:US
Mailing Address - Phone:925-201-6021
Mailing Address - Fax:925-201-6091
Practice Address - Street 1:4361 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6611
Practice Address - Country:US
Practice Address - Phone:925-201-6021
Practice Address - Fax:925-201-6091
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine