Healthcare Provider Details

I. General information

NPI: 1700066149
Provider Name (Legal Business Name): MARYAM RAHIMI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19066 MAGNOLIA ST
HUNTINGTON BEACH CA
92646-2232
US

IV. Provider business mailing address

5318 E 2ND ST # 670
LONG BEACH CA
90803-5324
US

V. Phone/Fax

Practice location:
  • Phone: 949-610-1042
  • Fax: 949-610-1049
Mailing address:
  • Phone: 949-610-1042
  • Fax: 949-610-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number005474
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A10143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: