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General NPI Number Information
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NPI Number | 1154811271
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Entity Type | Individual
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Provider Name | MARYAM TAVANAEI MD
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Gender | Female
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Dates
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Enumeration Date | 05/14/2018
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 12660 RIVERSIDE DR STE 215
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91607-3430
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Country | US
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Telephone | 424-314-7660
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Fax |
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Provider Business Mailing Address
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Address Line | 400 W PUEBLO ST OFC
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City | SANTA BARBARA
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State | CA
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Zip | 93105-4353
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | A173242
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License Number State | CA
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