Provider Demographics
NPI:1316300809
Name:GOLESTANI, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:GOLESTANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10806
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5806
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-1439
Practice Address - Street 1:101 DATES DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1342
Practice Address - Country:US
Practice Address - Phone:607-274-4474
Practice Address - Fax:207-777-1439
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT67181207ZP0102X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology