Healthcare Provider Details

I. General information

NPI: 1497769731
Provider Name (Legal Business Name): MARIAM AMIRI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11332 MOUNTAIN VIEW AVE SUITE A
LOMA LINDA CA
92354-3854
US

IV. Provider business mailing address

PO BOX 1059
LOMA LINDA CA
92354-1059
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-3707
  • Fax: 909-796-3709
Mailing address:
  • Phone: 909-796-3707
  • Fax: 909-796-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4049
License Number StateCA

VIII. Authorized Official

Name: DR. MARIAM SHANAZ AMIRI
Title or Position: OWNER
Credential: MD
Phone: 909-796-3707