Provider Demographics
NPI:1104098292
Name:MOHAMED, REZAH SHOVAL (DO)
Entity type:Individual
Prefix:DR
First Name:REZAH
Middle Name:SHOVAL
Last Name:MOHAMED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:REZAH
Other - Middle Name:SHOVAL
Other - Last Name:MOHAMED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1537 W 7TH STREET
Mailing Address - Street 2:APT 214
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:312-286-3193
Mailing Address - Fax:
Practice Address - Street 1:17310 BEAR VALLEY ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-241-4499
Practice Address - Fax:760-243-9474
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA12960152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist