Provider Demographics
NPI:1720145147
Name:EMAMI, MITRA (MD)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:EMAMI
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 1:2516 SAMARITAN DR
Mailing Address - Street 2:SUITE K
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4108
Mailing Address - Country:US
Mailing Address - Phone:408-358-6525
Mailing Address - Fax:
Practice Address - Street 1:2516 SAMARITAN DR
Practice Address - Street 2:SUITE K
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4108
Practice Address - Country:US
Practice Address - Phone:408-358-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA066854174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24681ZMedicare ID - Type Unspecified