Healthcare Provider Details

I. General information

NPI: 1053477703
Provider Name (Legal Business Name): REZA YAVARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MAIN ST
BRANFORD CT
06405-3773
US

IV. Provider business mailing address

1008 MAIN ST
BRANFORD CT
06405-3773
US

V. Phone/Fax

Practice location:
  • Phone: 203-315-2936
  • Fax: 203-315-2940
Mailing address:
  • Phone: 203-315-2936
  • Fax: 203-315-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number032568
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number032568
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: