Healthcare Provider Details

I. General information

NPI: 1811287394
Provider Name (Legal Business Name): MARYAM SHARIF-HASSANABADI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 09/16/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

101 BODIN CIR NEPHROLOGY(60MDOS/SGOMKH)
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-2570
  • Fax:
Mailing address:
  • Phone: 707-816-5930
  • Fax: 707-816-5665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA116460
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA116460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: