Provider Demographics
NPI:1396936217
Name:ARDALAN, MARYAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:ARDALAN
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 1:25425 ORCHARD VILLAGE RD STE 270
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-2958
Mailing Address - Country:US
Mailing Address - Phone:661-260-1282
Mailing Address - Fax:661-254-4212
Practice Address - Street 1:25425 ORCHARD VILLAGE RD STE 270
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-2958
Practice Address - Country:US
Practice Address - Phone:661-260-1282
Practice Address - Fax:661-414-8047
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102198207VX0000X, 207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1021980Medicaid
CA0A1021980OtherBLUE SHIELD
CA0A1021980OtherBLUE SHIELD
CACO941WMedicare PIN