=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497769731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIAM AMIRI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2006
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11332 MOUNTAIN VIEW AVE SUITE A
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-796-3707
-----------------------------------------------------
Fax | 909-796-3709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1059
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-1059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-796-3707
-----------------------------------------------------
Fax | 909-796-3709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARIAM SHANAZ AMIRI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-796-3707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | E4049
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------