Provider Demographics
NPI:1902656630
Name:AMIRI, IDEN M
Entity Type:Individual
Prefix:
First Name:IDEN
Middle Name:M
Last Name:AMIRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 LA VILLA MARINA UNIT F
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7082
Mailing Address - Country:US
Mailing Address - Phone:310-740-7656
Mailing Address - Fax:
Practice Address - Street 1:4812 LA VILLA MARINA UNIT F
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7082
Practice Address - Country:US
Practice Address - Phone:310-740-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program