Healthcare Provider Details

I. General information

NPI: 1194898064
Provider Name (Legal Business Name): MAHINDOKHT MARY RAISZADEH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5222 BALBOA AVE STE 45
SAN DIEGO CA
92117-6904
US

IV. Provider business mailing address

5222 BALBOA AVE STE 45
SAN DIEGO CA
92117-6904
US

V. Phone/Fax

Practice location:
  • Phone: 858-616-6430
  • Fax:
Mailing address:
  • Phone: 858-616-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA34656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: