Provider Demographics
NPI:1194724583
Name:GHOLIZADEH, MARYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:GHOLIZADEH
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 1:1120 W LA VETA AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4231
Mailing Address - Country:US
Mailing Address - Phone:714-289-4704
Mailing Address - Fax:
Practice Address - Street 1:1120 W LA VETA AVE
Practice Address - Street 2:STE. 100
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4231
Practice Address - Country:US
Practice Address - Phone:714-289-4704
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA839352086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A839350Medicaid
H70577Medicare UPIN
WA83935AMedicare ID - Type Unspecified