MEDICARE: MOHAMMAD REZA DANESHVAR DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501015767	MI

General Provider Information

NPI Number	:	1952640443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMMAD REZA DANESHVAR DPT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	248-231-5522
Fax Number	:

Provider Business Practice Location Address
First Line	:	10636 W 7 MILE RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-1969
Country	:	US
Telephone Number	:	313-862-1340
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2013
Last Update Date	:	07/06/2018

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