Healthcare Provider Details

I. General information

NPI: 1679662472
Provider Name (Legal Business Name): ENAYATOLLAH REZVANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 W CENTRAL ROAD SUITE 204
ARLINGTON HEIGHTS IL
60005-2364
US

IV. Provider business mailing address

605 W CENTRAL ROAD SUITE 204
ARLINGTON HEIGHTS IL
60005-2364
US

V. Phone/Fax

Practice location:
  • Phone: 847-259-2620
  • Fax: 847-259-6409
Mailing address:
  • Phone: 847-259-2620
  • Fax: 847-259-6409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: