Provider Demographics
NPI:1861913683
Name:SADEGHI, MARYAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:SADEGHI
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 1:1050 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-3414
Mailing Address - Country:US
Mailing Address - Phone:707-463-7488
Mailing Address - Fax:707-468-0890
Practice Address - Street 1:1050 N STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3414
Practice Address - Country:US
Practice Address - Phone:707-463-7488
Practice Address - Fax:707-468-0890
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1951502083P0500X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4301112834OtherGENERAL SURGERY RESIDENT