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General NPI Number Information
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NPI Number | 1366538183
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Entity Type | Organization
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Legal Business Name | ABOLGHASEM REZAEI MD PC
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 03/27/2021
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Provider Practice Location Address
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Address Line | 4121 W GORE BLVD
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City | LAWTON
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State | OK
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Zip | 73505-6336
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Country | US
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Telephone | 580-699-5511
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Fax | 580-699-5519
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Provider Business Mailing Address
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Address Line | 4121 W GORE BLVD
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City | LAWTON
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State | OK
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Zip | 73505-6336
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Country | US
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Telephone | 580-699-5511
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Fax | 580-995-5196
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Authorized Official
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Title or Position | OWNER
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Name | DR. ABOLGHASEM MARCO REZAEI
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Credential | MD
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Telephone | 580-699-5511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 23655
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License Number State | OK
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