Provider Demographics
NPI:1962584920
Name:BAYATI, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:BAYATI
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 1:5120 WARD LN
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2842
Mailing Address - Country:US
Mailing Address - Phone:916-500-2474
Mailing Address - Fax:916-626-4837
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:WOUND CARE CLINIC
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3037
Practice Address - Country:US
Practice Address - Phone:916-781-1386
Practice Address - Fax:916-781-1456
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066754261QM2500X
CAC52426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4772285Medicaid
CA1962584920Medicare UPIN
MIG63608Medicare UPIN
CABT143AMedicare PIN
CABT143AMedicare PIN