Healthcare Provider Details

I. General information

NPI: 1235465089
Provider Name (Legal Business Name): REZA MESBAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: REZA MESBAH M.D

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1762 WESTWOOD BLVD STE 110
LOS ANGELES CA
90024-5622
US

IV. Provider business mailing address

7705 SEVILLE AVE STE B
HUNTINGTON PARK CA
90255-6570
US

V. Phone/Fax

Practice location:
  • Phone: 310-441-2000
  • Fax: 310-441-2020
Mailing address:
  • Phone: 323-275-9977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberC168003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101248524
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number261697
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: