Healthcare Provider Details

I. General information

NPI: 1720026792
Provider Name (Legal Business Name): KIANOUSH V REZAEI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 E MAIN ST BOX 328
KENT OH
44240-5818
US

IV. Provider business mailing address

1675 E MAIN ST BOX 328
KENT OH
44240-5818
US

V. Phone/Fax

Practice location:
  • Phone: 330-593-1048
  • Fax: 330-572-3836
Mailing address:
  • Phone: 330-593-1048
  • Fax: 330-572-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME 101918
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.125669
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: