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General NPI Number Information
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NPI Number | 1023352069
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Entity Type | Organization
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Legal Business Name | ADVANCED ALLERGY INC
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 5512 GLENRIDGE DR NE UNIT A
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City | ATLANTA
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State | GA
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Zip | 30342-7213
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Country | US
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Telephone | 404-983-2034
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Fax |
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Provider Business Mailing Address
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Address Line | 5512 GLENRIDGE DR NE UNIT A
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City | ATLANTA
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State | GA
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Zip | 30342-7213
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Country | US
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Telephone | 404-983-2034
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MAZIAR REZVANI
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Credential | M.D.
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Telephone | 404-983-2034
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 053937
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License Number State | GA
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