Healthcare Provider Details

I. General information

NPI: 1770701542
Provider Name (Legal Business Name): MARYAM REZVANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NORTH 1900 EAST #1A71
SALT LAKE CITY UT
84132
US

IV. Provider business mailing address

30 N 1900 E #1A71
SALT LAKE CITY UT
84132-2140
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-8699
  • Fax: 801-581-2414
Mailing address:
  • Phone: 801-581-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number65868131205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number036-115412
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number01060592A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number6586813-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: