Healthcare Provider Details

I. General information

NPI: 1508022781
Provider Name (Legal Business Name): AZADEH REZVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 SE SUNNYSIDE RD MT TALERT MEDICAL OFFICE, DIVISION OF UROGYNECOLOGY
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10100 SE SUNNYSIDE RD. MT TALBERT MEDICAL OFFICE, DEPARTMENT OF OB/GYN, DIVISION OF UROGYNECOLOGY
CLACKAMAS OR
97015
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-2880
  • Fax:
Mailing address:
  • Phone: 503-652-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD171989
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: