Provider Demographics
NPI:1750888111
Name:MOGHAREH, MARYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOGHAREH
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 1:670 GLADES RD STE 400
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6464
Mailing Address - Country:US
Mailing Address - Phone:561-955-2570
Mailing Address - Fax:561-955-2572
Practice Address - Street 1:670 GLADES RD STE 400
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6464
Practice Address - Country:US
Practice Address - Phone:561-955-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME157239207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAXUQ201916523OtherBLUE CROSS BLUE SHIELD HMO