Healthcare Provider Details

I. General information

NPI: 1487976668
Provider Name (Legal Business Name): MOHAMMAD REZVANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3392 MOTOR AVE
LOS ANGELES CA
90034-3712
US

IV. Provider business mailing address

11693 SAN VICENTE BLVD # 389
LOS ANGELES CA
90049-5105
US

V. Phone/Fax

Practice location:
  • Phone: 310-858-5090
  • Fax: 310-424-3404
Mailing address:
  • Phone: 310-858-5090
  • Fax: 310-424-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number4301086547
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA113116
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberA113116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: