Healthcare Provider Details

I. General information

NPI: 1750887634
Provider Name (Legal Business Name): SANAYA HORMOZDYARAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2018
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 TRUXTUN RD STE 120A
SAN DIEGO CA
92106-6135
US

IV. Provider business mailing address

9850 GENESEE AVE STE 320
LA JOLLA CA
92037-1208
US

V. Phone/Fax

Practice location:
  • Phone: 619-222-1253
  • Fax: 858-795-1195
Mailing address:
  • Phone: 858-554-1212
  • Fax: 858-795-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number309521-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA182627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: