Healthcare Provider Details

I. General information

NPI: 1386849958
Provider Name (Legal Business Name): HEIDI GOODARZI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 507
ORANGE CA
92868-3856
US

IV. Provider business mailing address

366 SAN MIGUEL DR STE 201
NEWPORT BEACH CA
92660-7810
US

V. Phone/Fax

Practice location:
  • Phone: 949-679-1990
  • Fax:
Mailing address:
  • Phone: 949-430-0334
  • Fax: 949-430-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA107754
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA107754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: