Basic Information
| Provider Information | |||||||||
| NPI: | 1376735688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEHYAR | ||||||||
| FirstName: | MARIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEHYAR-POPAL | ||||||||
| OtherFirstName: | MARIAM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31588 RAILROAD CANYON RD | ||||||||
| Address2: | |||||||||
| City: | CANYON LAKE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925879468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514710888 | ||||||||
| FaxNumber: | 9514712965 | ||||||||
| Practice Location | |||||||||
| Address1: | 27168 NEWPORT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925847383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512463033 | ||||||||
| FaxNumber: | 9512467373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2007 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A102480 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.