Healthcare Provider Details

I. General information

NPI: 1124349980
Provider Name (Legal Business Name): REZA SHAHBAZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 CITY DRIVE
ORANGE CA
92868
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-9870
  • Fax:
Mailing address:
  • Phone: 714-456-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA106268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: