1366607988 NPI number — REZA BONABI MD, INC

Table of content: MEGHAN SMYTHE MA, MFT (NPI 1760920680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366607988 NPI number — REZA BONABI MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REZA BONABI MD, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1366607988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17075 DEVONSHIRE ST
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
NORTHRIDGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91325-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-368-4212
Provider Business Mailing Address Fax Number:
818-366-9351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17075 DEVONSHIRE ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-368-4212
Provider Business Practice Location Address Fax Number:
818-366-9351
Provider Enumeration Date:
07/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BONABI
Authorized Official First Name:
NAGADEH
Authorized Official Middle Name:
GHOLAMREZA
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
818-368-4212

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A46355 , 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)

  • Identifier: 00A463550 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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