1245393602 NPI number — MARYAM RAHBAR, MD, INC.

Table of content: (NPI 1245393602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245393602 NPI number — MARYAM RAHBAR, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYAM RAHBAR, MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1245393602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11869
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92658-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-847-3666
Provider Business Mailing Address Fax Number:
714-847-7171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17822 BEACH BLVD STE 101
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:
92647-7179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-847-3666
Provider Business Practice Location Address Fax Number:
714-847-7171
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAHBAR
Authorized Official First Name:
MARYAM
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
714-847-3666

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  AAAHC 77516 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X , with the licence number: A2677838 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 05D1073514 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A267838 . This is a "CITY BUSINESS LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 77516 . This is a "AAAHC ACCREDITATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FNP36985 . This is a "FICTITIOUS NAME PERMIT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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