Healthcare Provider Details

I. General information

NPI: 1396936217
Provider Name (Legal Business Name): MARYAM ARDALAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25425 ORCHARD VILLAGE RD STE 270
SANTA CLARITA CA
91355-2958
US

IV. Provider business mailing address

25425 ORCHARD VILLAGE RD STE 270
SANTA CLARITA CA
91355-2958
US

V. Phone/Fax

Practice location:
  • Phone: 661-260-1282
  • Fax: 661-414-8047
Mailing address:
  • Phone: 661-260-1282
  • Fax: 661-254-4212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA102198
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA102198
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA102198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: