Healthcare Provider Details

I. General information

NPI: 1689319204
Provider Name (Legal Business Name): HEIDI GOODARZI, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
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

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

V. Phone/Fax

Practice location:
  • Phone: 949-679-1990
  • Fax: 949-430-0336
Mailing address:
  • Phone: 863-420-4807
  • Fax: 866-803-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. HEIDI GOODARZI
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 949-412-9450