Healthcare Provider Details

I. General information

NPI: 1316436694
Provider Name (Legal Business Name): ERONA REZA MBBS, CCFP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 UNIVERSITY TOWN CENTRE DRIVE
MORGANTOWN WV
26501-2421
US

IV. Provider business mailing address

6040 UNIVERSITY TOWN CENTRE DRIVE
MORGANTOWN WV
26501-2421
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-6900
  • Fax: 304-285-7372
Mailing address:
  • Phone: 304-598-6900
  • Fax: 304-285-7372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number1013
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: