Healthcare Provider Details

I. General information

NPI: 1538418884
Provider Name (Legal Business Name): MARIAM LANTIN ABDUL-LATIF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIAM LANTIN ABDULLATIF M.D.

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S BLDG 56, STE 600, ZOT 4490
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S BLDG 56, STE 600, ZOT 4490
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6920
  • Fax: 714-456-7658
Mailing address:
  • Phone: 714-456-6920
  • Fax: 714-456-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA122693
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: