Healthcare Provider Details

I. General information

NPI: 1487602116
Provider Name (Legal Business Name): AMADI REZAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 ROUTE 72 EAST SUITE 1
MANAHAWKIN NJ
08050-2899
US

IV. Provider business mailing address

602 ROUTE 72 EAST SUITE 1
MANAHAWKIN NJ
08050-2899
US

V. Phone/Fax

Practice location:
  • Phone: 609-978-9870
  • Fax: 609-978-9873
Mailing address:
  • Phone: 609-978-9870
  • Fax: 609-978-9873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA076703
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA07670300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: