Provider Demographics
NPI:1215201108
Name:BALOUCH, MARYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:BALOUCH
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:15611 POMERADO RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2437
Mailing Address - Country:US
Mailing Address - Phone:858-675-3100
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:1955 CITRACADO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4110
Practice Address - Country:US
Practice Address - Phone:760-743-0546
Practice Address - Fax:760-743-8837
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2024-03-25
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Provider Licenses
StateLicense IDTaxonomies
CAA121988207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113998OtherSID # 113998