Provider Demographics
NPI:1194354944
Name:SHAHAMFAR, MARYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:SHAHAMFAR
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-8000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-333-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA183299207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology