Provider Demographics
NPI:1760663116
Name:MIREMADI DERMATOLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MIREMADI DERMATOLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARJANG
Authorized Official - Middle Name:K
Authorized Official - Last Name:MIREMADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-456-1840
Mailing Address - Street 1:7702 IVANHOE AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4520
Mailing Address - Country:US
Mailing Address - Phone:858-456-1840
Mailing Address - Fax:
Practice Address - Street 1:7702 IVANHOE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4520
Practice Address - Country:US
Practice Address - Phone:858-456-1840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31016207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310160Medicaid
CA00A310160Medicaid