Provider Demographics
NPI:1760740427
Name:SANJARI, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:SANJARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0620
Mailing Address - Country:US
Mailing Address - Phone:909-383-3001
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST,
Practice Address - Street 2:GME OFFICE, CSP 21005
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1331872083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine