Provider Demographics
NPI:1306136718
Name:JAN, MARIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:JAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:IKHLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:29525 CANWOOD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4232
Mailing Address - Country:US
Mailing Address - Phone:818-706-2477
Mailing Address - Fax:818-706-2368
Practice Address - Street 1:29525 CANWOOD ST STE 300
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4232
Practice Address - Country:US
Practice Address - Phone:818-706-2477
Practice Address - Fax:818-706-2368
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA131530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine