1215201108 NPI number — MARYAM BALOUCH M.D.

Table of content: MARYAM BALOUCH M.D. (NPI 1215201108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215201108 NPI number — MARYAM BALOUCH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALOUCH
Provider First Name:
MARYAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215201108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15611 POMERADO RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
POWAY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92064-2437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-675-3100
Provider Business Mailing Address Fax Number:
858-618-1523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 CITRACADO PKWY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92029-4110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-743-0546
Provider Business Practice Location Address Fax Number:
760-743-8837
Provider Enumeration Date:
02/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  A121988 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113998 . This is a "SID # 113998" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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