MEDICARE: MARYAM MORTEZAIEFARD D.O.

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	207R00000X	Internal Medicine Physician	20A7100	CA

General Provider Information

NPI Number	:	1285653196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYAM MORTEZAIEFARD D.O.

Provider Business Mailing Address
First Line	:	22110 ROSCOE BLVD
Second Line	:	SUITE 100
City	:	WEST HILLS
State	:	CA
Zip	:	91304-3845
Country	:	US
Telephone Number	:	818-888-8042
Fax Number	:

Provider Business Practice Location Address
First Line	:	22110 ROSCOE BLVD
Second Line	:	SUITE 100
City	:	WEST HILLS
State	:	CA
Zip	:	91304-3845
Country	:	US
Telephone Number	:	818-888-8042
Fax Number	:

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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