Healthcare Provider Details

I. General information

NPI: 1013399195
Provider Name (Legal Business Name): MOHAMMED TAGHI REZAI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E THOUSAND OAKS BLVD STE B
THOUSAND OAKS CA
91360-5800
US

IV. Provider business mailing address

455 E THOUSAND OAKS BLVD STE B
THOUSAND OAKS CA
91360-5800
US

V. Phone/Fax

Practice location:
  • Phone: 818-232-5788
  • Fax:
Mailing address:
  • Phone: 818-232-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number20A14895
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number20A14895
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A14895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: