Provider Demographics
NPI:1487976668
Name:REZVANI, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:REZVANI
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 1:11693 SAN VICENTE BLVD # 389
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5105
Mailing Address - Country:US
Mailing Address - Phone:310-858-5090
Mailing Address - Fax:310-424-3404
Practice Address - Street 1:3392 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3712
Practice Address - Country:US
Practice Address - Phone:310-858-5090
Practice Address - Fax:310-424-3404
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086547207U00000X
CAA113116207R00000X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066315Medicaid
CAA113116OtherLICENSE
CAW13536CMedicare PIN