Provider Demographics
NPI:1427144666
Name:ELLINI, AHMAD REZA (MD)
Entity type:Individual
Prefix:
First Name:AHMAD REZA
Middle Name:
Last Name:ELLINI
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 1:1010 W LA VETA AVE
Mailing Address - Street 2:SUITE 575
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4300
Mailing Address - Country:US
Mailing Address - Phone:714-547-0900
Mailing Address - Fax:714-547-2080
Practice Address - Street 1:1010 W LA VETA AVE
Practice Address - Street 2:SUITE 575
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4300
Practice Address - Country:US
Practice Address - Phone:714-547-0900
Practice Address - Fax:714-547-2080
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD711882080P0202X
CAA1227532080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410880901Medicaid
MD189927ZAKHMedicare PIN