Healthcare Provider Details

I. General information

NPI: 1336175272
Provider Name (Legal Business Name): REZA SHIRAZI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 5TH AVE
SAN DIEGO CA
92103-5713
US

IV. Provider business mailing address

PO BOX 33865
SAN DIEGO CA
92163-3865
US

V. Phone/Fax

Practice location:
  • Phone: 619-230-0400
  • Fax: 858-429-7936
Mailing address:
  • Phone: 858-888-7700
  • Fax: 858-888-7721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA95800
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA95800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: