Healthcare Provider Details

I. General information

NPI: 1053013680
Provider Name (Legal Business Name): REZA NASROLLAHZADEH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MARIO CAPECCHI DR RM 3N100
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

30 N MARIO CAPECCHI DR RM 3N100
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-408-3617
  • Fax:
Mailing address:
  • Phone: 801-408-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number14283601-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: