Healthcare Provider Details

I. General information

NPI: 1679811202
Provider Name (Legal Business Name): MARYAM MALEKIAN MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N BASCOM AVE SUITE 204
SAN JOSE CA
95128-1811
US

IV. Provider business mailing address

105 N BASCOM AVE SUITE 204
SAN JOSE CA
95128-1811
US

V. Phone/Fax

Practice location:
  • Phone: 408-918-0400
  • Fax: 408-286-2922
Mailing address:
  • Phone: 408-918-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1049903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: