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General NPI Number Information
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NPI Number | 1407526270
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Entity Type | Organization
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Legal Business Name | MARYAMPOURSARTIPMD INC.
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Dates
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Enumeration Date | 09/14/2021
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Last Update Date | 12/21/2021
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Provider Practice Location Address
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Address Line | 665 CAMINO DE LOS MARES STE 305
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-2841
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Country | US
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Telephone | 949-371-9259
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Fax |
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Provider Business Mailing Address
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Address Line | 258 WHITE CAP LN
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City | NEWPORT COAST
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State | CA
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Zip | 92657-1088
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Country | US
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Telephone | 917-575-6669
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Fax |
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Authorized Official
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Title or Position | INTERNAL MEDICINE
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Name | DR. MARYAM POURSARTIP
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Credential | MD
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Telephone | 917-575-6669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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