MEDICARE: REZA RAY EHSAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	A50372	CA
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	A50372	CA
3	207Q00000X	Family Medicine Physician	A50372	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467537480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REZA RAY EHSAN M.D.

Provider Business Mailing Address
First Line	:	11600 VENICE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-4014
Country	:	US
Telephone Number	:	310-390-9551
Fax Number	:	310-390-9296

Provider Business Practice Location Address
First Line	:	11600 VENICE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-4014
Country	:	US
Telephone Number	:	310-390-9551
Fax Number	:	310-390-9296

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	01/05/2016

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