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General NPI Number Information
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NPI Number | 1104098292
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Entity Type | Individual
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Provider Name | REZAH SHOVAL MOHAMED D.O
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Gender | Male
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Dates
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Enumeration Date | 03/28/2008
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Last Update Date | 03/28/2008
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Provider Practice Location Address
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Address Line | 17310 BEAR VALLEY ROAD SUITE 101
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City | VICTORVILLE
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State | CA
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Zip | 92395
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Country | US
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Telephone | 760-241-4499
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Fax | 760-243-9474
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Provider Business Mailing Address
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Address Line | 1537 W 7TH STREET APT 214
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City | UPLAND
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State | CA
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Zip | 91786
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Country | US
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Telephone | 312-286-3193
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | CA12960
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License Number State | CA
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