Healthcare Provider Details

I. General information

NPI: 1518698646
Provider Name (Legal Business Name): BRANDON KEVIN TIMUR REZZADEH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 MAIN ST
PATERSON NJ
07503-2621
US

IV. Provider business mailing address

3130 ANTELO RD
LOS ANGELES CA
90077-1604
US

V. Phone/Fax

Practice location:
  • Phone: 551-206-4444
  • Fax:
Mailing address:
  • Phone: 551-206-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number207XX0801X
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: