Provider Demographics
NPI:1922185966
Name:ANDERSON, KATHY MIRZABOZORG (MD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:MIRZABOZORG
Last Name:ANDERSON
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 1:801 N TUSTIN AVE
Mailing Address - Street 2:STE 403
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3608
Mailing Address - Country:US
Mailing Address - Phone:714-547-7575
Mailing Address - Fax:714-547-8881
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:STE 403
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3608
Practice Address - Country:US
Practice Address - Phone:714-547-7575
Practice Address - Fax:714-547-8881
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78317207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14517Medicare ID - Type Unspecified
WG78317AMedicare PIN
G24911Medicare UPIN