Healthcare Provider Details

I. General information

NPI: 1356578835
Provider Name (Legal Business Name): MARIAM YAZDIPOUR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S SEPULVEDA BLVD STE 200
MANHATTAN BEACH CA
90266-6876
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 310-546-3461
  • Fax:
Mailing address:
  • Phone: 310-792-3914
  • Fax: 855-898-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMT191749
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC144316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: