Healthcare Provider Details

I. General information

NPI: 1922042092
Provider Name (Legal Business Name): REZA VAEZAZIZI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36485 INLAND VALLEY DRIVE
WILDOMAR CA
92595
US

IV. Provider business mailing address

2100 POWELL STREET SUITE 900
EMERYVILLE CA
94608-1803
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-9712
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA66886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: