MEDICARE: MARYAM MOKHTARZADEH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	A104706	CA

General Provider Information

NPI Number	:	1164629150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYAM MOKHTARZADEH M.D.

Provider Business Mailing Address
First Line	:	2201 S BEVERLY GLEN BLVD
Second Line	:	APT.#304
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2415
Country	:	US
Telephone Number	:	248-219-5039
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 S BEVERLY GLEN BLVD
Second Line	:	APT.#304
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2415
Country	:	US
Telephone Number	:	248-219-5039
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	10/05/2009

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