Healthcare Provider Details

I. General information

NPI: 1497757660
Provider Name (Legal Business Name): MOHAMMAD REZA MIZANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: M. REZA MIZANI M.D

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N SAN SABA STE 301
SAN ANTONIO TX
78207-8101
US

IV. Provider business mailing address

PO BOX 650002 DEPT 8286
DALLAS TX
75265-0002
US

V. Phone/Fax

Practice location:
  • Phone: 210-212-8622
  • Fax: 210-212-9197
Mailing address:
  • Phone: 210-212-8622
  • Fax: 210-212-9197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL2477
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberL2477
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: