Healthcare Provider Details

I. General information

NPI: 1730684234
Provider Name (Legal Business Name): NIMA REJALI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 09/26/2023
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

11 SCHINDLER CT APT 3
MIDDLETOWN NY
10940-2011
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2000
  • Fax:
Mailing address:
  • Phone: 949-813-6759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number308082
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: