Provider Demographics
NPI:1215934468
Name:MAVANDADI, AZITA (PHARMD)
Entity type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:MAVANDADI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-3110
Mailing Address - Country:US
Mailing Address - Phone:949-640-6330
Mailing Address - Fax:
Practice Address - Street 1:19066 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2232
Practice Address - Country:US
Practice Address - Phone:714-968-0068
Practice Address - Fax:714-378-2188
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49724208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0497240OtherMEDI CAL