Healthcare Provider Details

I. General information

NPI: 1760740427
Provider Name (Legal Business Name): MARYAM SANJARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST, GME OFFICE, CSP 21005
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

606 E MILL ST
SAN BERNARDINO CA
92415-0620
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4918
  • Fax:
Mailing address:
  • Phone: 909-383-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA133187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: