Healthcare Provider Details

I. General information

NPI: 1962584920
Provider Name (Legal Business Name): REZA BAYATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA DR WOUND CARE CLINIC
ROSEVILLE CA
95661-3037
US

IV. Provider business mailing address

5120 WARD LN
ROCKLIN CA
95677-2842
US

V. Phone/Fax

Practice location:
  • Phone: 916-781-1386
  • Fax: 916-781-1456
Mailing address:
  • Phone: 916-500-2474
  • Fax: 916-626-4837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number4301066754
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC52426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: