MEDICARE: DR. MARYAM ARDALAN MD

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	207VX0000X	Obstetrics Physician	A102198	CA
2	207V00000X	Obstetrics & Gynecology Physician	A102198	CA
3	207VG0400X	Gynecology Physician	A102198	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0A1021980	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1396936217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYAM ARDALAN MD

Provider Business Mailing Address
First Line	:	25425 ORCHARD VILLAGE RD STE 270
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91355-2958
Country	:	US
Telephone Number	:	661-260-1282
Fax Number	:	661-254-4212

Provider Business Practice Location Address
First Line	:	25425 ORCHARD VILLAGE RD STE 270
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91355-2958
Country	:	US
Telephone Number	:	661-260-1282
Fax Number	:	661-414-8047

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	02/22/2023

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