Healthcare Provider Details

I. General information

NPI: 1568848042
Provider Name (Legal Business Name): REZA KERMANI MD INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 10/07/2023
Certification Date: 10/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38920 TRADE CENTER DR
PALMDALE CA
93551-3715
US

IV. Provider business mailing address

35 E GLENARM ST
PASADENA CA
91105-3418
US

V. Phone/Fax

Practice location:
  • Phone: 612-554-4106
  • Fax: 972-323-7840
Mailing address:
  • Phone: 626-768-4415
  • Fax: 626-403-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberA111955
License Number StateCA

VIII. Authorized Official

Name: REZA KERMANI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-920-6925