Healthcare Provider Details

I. General information

NPI: 1255376810
Provider Name (Legal Business Name): REZA MAHROU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: REZA MAHROU M.D.

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WATERWORKS WAY SUITE 345
IRVINE CA
92618-3167
US

IV. Provider business mailing address

PO BOX 54788
IRVINE CA
92619-4788
US

V. Phone/Fax

Practice location:
  • Phone: 949-872-2400
  • Fax: 949-872-2401
Mailing address:
  • Phone: 949-872-2400
  • Fax: 949-872-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA76865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: