Provider Demographics
NPI:1154811271
Name:TAVANAEI, MARYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:TAVANAEI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W PUEBLO ST OFC
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12660 RIVERSIDE DR STE 215
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3430
Practice Address - Country:US
Practice Address - Phone:424-314-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA173242207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program