Provider Demographics
NPI:1891382495
Name:MEHRZAD, MARYAM (OD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MEHRZAD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6748 ELEGANTE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-5401
Mailing Address - Country:US
Mailing Address - Phone:858-335-9116
Mailing Address - Fax:
Practice Address - Street 1:3720 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4112
Practice Address - Country:US
Practice Address - Phone:858-335-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist