Healthcare Provider Details

I. General information

NPI: 1720049810
Provider Name (Legal Business Name): MOHAMMAD REZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20455 LORAIN RD SUITE T04
FAIRVIEW PARK OH
44126-3494
US

IV. Provider business mailing address

PO BOX 450923
WESTLAKE OH
44145-0621
US

V. Phone/Fax

Practice location:
  • Phone: 440-333-5767
  • Fax: 440-333-5768
Mailing address:
  • Phone: 444-333-5767
  • Fax: 440-333-5768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-076235
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: