Provider Demographics
NPI:1417343690
Name:DIVA MD
Entity type:Organization
Organization Name:DIVA MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAZANIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRAREFI
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:949-694-1357
Mailing Address - Street 1:23152 VERDUGO DR STE 102
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1373
Mailing Address - Country:US
Mailing Address - Phone:949-694-1357
Mailing Address - Fax:949-818-2490
Practice Address - Street 1:23152 VERDUGO DR STE 102
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1373
Practice Address - Country:US
Practice Address - Phone:949-694-1357
Practice Address - Fax:949-818-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261Q00000X
CA207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty