Provider Demographics
NPI:1487757589
Name:MIRKARIMI, MORTEZA (MD)
Entity type:Individual
Prefix:
First Name:MORTEZA
Middle Name:
Last Name:MIRKARIMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 CLAIREMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5831
Mailing Address - Country:US
Mailing Address - Phone:858-483-5570
Mailing Address - Fax:858-483-5572
Practice Address - Street 1:3863 CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117
Practice Address - Country:US
Practice Address - Phone:858-483-5570
Practice Address - Fax:858-483-5572
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39662208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487757589OtherNEW NPI NUMBER FOR CORPORATION
CA00A39662Medicaid
A85317Medicare UPIN