Healthcare Provider Details

I. General information

NPI: 1376988535
Provider Name (Legal Business Name): REZA EHSANIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 04/12/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

PO BOX 91902
ALBUQUERQUE NM
87199-1902
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD2021-0789
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: