Provider Demographics
NPI:1851598866
Name:MARYSKA, DORSA F (MD)
Entity Type:Individual
Prefix:DR
First Name:DORSA
Middle Name:F
Last Name:MARYSKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DORSA
Other - Middle Name:F
Other - Last Name:NASSERI-NOORI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:101 E BEVERLY BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4316
Mailing Address - Country:US
Mailing Address - Phone:323-722-7418
Mailing Address - Fax:323-722-7894
Practice Address - Street 1:101 E BEVERLY BLVD STE 304
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4316
Practice Address - Country:US
Practice Address - Phone:323-722-7418
Practice Address - Fax:323-722-7894
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97299207R00000X
CAA92799207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACS168YMedicaid
EF647AMedicare PIN