Healthcare Provider Details

I. General information

NPI: 1114921673
Provider Name (Legal Business Name): MARYAM RAHNEMUN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 CULVER DR STE 105
IRVINE CA
92604-0322
US

IV. Provider business mailing address

PO BOX 18588
IRVINE CA
92623-8588
US

V. Phone/Fax

Practice location:
  • Phone: 949-612-6050
  • Fax:
Mailing address:
  • Phone: 714-547-1700
  • Fax: 714-547-1771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA53377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: