Healthcare Provider Details

I. General information

NPI: 1104887694
Provider Name (Legal Business Name): FRED REZVANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 PROSPECT ST 1ST FLOOR SUITE 1
RIDGEWOOD NJ
07450-4405
US

IV. Provider business mailing address

119 PROSPECT ST 1ST FLOOR SUITE 1
RIDGEWOOD NJ
07450-4405
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-1600
  • Fax: 201-444-8774
Mailing address:
  • Phone: 201-444-1600
  • Fax: 201-444-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA05115800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: