Provider Demographics
NPI:1194888644
Name:REZVAN, NADER (MD)
Entity type:Individual
Prefix:
First Name:NADER
Middle Name:
Last Name:REZVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 N DUNN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-1327
Mailing Address - Country:US
Mailing Address - Phone:866-483-4804
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2317
Practice Address - Country:US
Practice Address - Phone:866-483-4804
Practice Address - Fax:317-870-0499
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023405174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100182840AMedicaid
IN547540IMedicare PIN
IN100182840AMedicaid