1720049810 NPI number — DR. MOHAMMAD REZA MD

Table of content: DR. MOHAMMAD REZA MD (NPI 1720049810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720049810 NPI number — DR. MOHAMMAD REZA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REZA
Provider First Name:
MOHAMMAD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1720049810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 450923
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145-0621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
444-333-5767
Provider Business Mailing Address Fax Number:
440-333-5768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20455 LORAIN RD
Provider Second Line Business Practice Location Address:
SUITE T04
Provider Business Practice Location Address City Name:
FAIRVIEW PARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44126-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-333-5767
Provider Business Practice Location Address Fax Number:
440-333-5768
Provider Enumeration Date:
03/29/2006

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: 207R00000X , with the licence number:  35-076235 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04 06811 . This is a "EVERCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3810004119 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300230243026 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2177522 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000333406 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 91894 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: F76235 . This is a "SUMMACARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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