Provider Demographics
NPI:1962616607
Name:FATOURECHI-ALSHARIF, MITRA M (MD)
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:M
Last Name:FATOURECHI-ALSHARIF
Suffix:
Gender:
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:PO BOX 2879
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92690-0879
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 VICTORIA ST STE 2F
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1906
Practice Address - Country:US
Practice Address - Phone:949-650-0630
Practice Address - Fax:949-650-3754
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108327207RE0101X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN332437200Medicaid
MN110011476Medicare PIN