1215934468 NPI number — AZITA MAVANDADI PHARMD

Table of content: AZITA MAVANDADI PHARMD (NPI 1215934468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215934468 NPI number — AZITA MAVANDADI PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAVANDADI
Provider First Name:
AZITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1215934468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4607 FAIRFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA DEL MAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92625-3110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-640-6330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19066 MAGNOLIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92646-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-968-0068
Provider Business Practice Location Address Fax Number:
714-378-2188
Provider Enumeration Date:
07/01/2005

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: 208U00000X , with the licence number:  49724 , 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: 0497240 . This is a "MEDI CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com