Healthcare Provider Details

I. General information

NPI: 1316569049
Provider Name (Legal Business Name): ROXANNE REZAEI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 PORTAGE TRAIL EXT W
CUYAHOGA FALLS OH
44223-1331
US

IV. Provider business mailing address

8815 GERMANTOWN AVE FL 5
PHILADELPHIA PA
19118-2722
US

V. Phone/Fax

Practice location:
  • Phone: 330-928-3111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.148964
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: