Healthcare Provider Details

I. General information

NPI: 1598096067
Provider Name (Legal Business Name): MARYAM M GHAVAMI-MAIBODI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYAM GHAVAMI MD

II. Dates (important events)

Enumeration Date: 01/24/2010
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

6430 W SUNSET BLVD SUITE 600
LOS ANGELES CA
90028-7900
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2450
  • Fax:
Mailing address:
  • Phone: 323-361-2337
  • Fax: 323-361-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA116322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: