Provider Demographics
NPI:1518760560
Name:MITRA FATOURECHI-ALSHARIF, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MITRA FATOURECHI-ALSHARIF, PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FATOURECHI-ALSHARIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-650-0630
Mailing Address - Street 1:275 VICTORIA ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1906
Mailing Address - Country:US
Mailing Address - Phone:949-650-0630
Mailing Address - Fax:
Practice Address - Street 1:275 VICTORIA ST STE 2F
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1906
Practice Address - Country:US
Practice Address - Phone:949-650-0630
Practice Address - Fax:949-650-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-27
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty