Provider Demographics
NPI:1104887694
Name:REZVANI, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:REZVANI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 PROSPECT ST
Mailing Address - Street 2:1ST FLOOR SUITE 1
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4405
Mailing Address - Country:US
Mailing Address - Phone:201-444-1600
Mailing Address - Fax:201-444-8774
Practice Address - Street 1:119 PROSPECT ST
Practice Address - Street 2:1ST FLOOR SUITE 1
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4405
Practice Address - Country:US
Practice Address - Phone:201-444-1600
Practice Address - Fax:201-444-8774
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05115800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ30G161OtherEMPIRE BC/BS OF NY
NJ4226530OtherAETNA PPO #
NJ0K6927OtherHEALTHNET #
NJBP204OtherOXFORD ID#
NJ0562861001OtherAMERIHEALTH #
NJ0028398OtherAETNA HMO #
NJ0562861001OtherAMERIHEALTH #