1295155109 NPI number — DR. PANTEHA REZAEIAN M.D.

Table of content: DR. PANTEHA REZAEIAN M.D. (NPI 1295155109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295155109 NPI number — DR. PANTEHA REZAEIAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REZAEIAN
Provider First Name:
PANTEHA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295155109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11234 ANDERSON ST
Provider Second Line Business Mailing Address:
GME OFFICE WESTERLY SUITE C
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-6688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 S. VICENTE AHSP 3106
Provider Second Line Business Practice Location Address:
127 S. VICENTE BLVD, AHSP A3200-06
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-247-3658
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  84828 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A143802 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)