Healthcare Provider Details

I. General information

NPI: 1124312475
Provider Name (Legal Business Name): NILOUFAR REISIAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S BLDG 1- ROOM 3003
ORANGE CA
92868-3201
US

IV. Provider business mailing address

4647 ZION AVE ROOM B738B
SAN DIEGO CA
92120-2507
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6141
  • Fax:
Mailing address:
  • Phone: 619-528-5387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: