Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0103X | Foot & Ankle Surgery | 1714 | TX |
NPI | 1013962539 |
---|---|
Provider Name | Dr. Reza Mobarak |
First Address | Lewisville, TX 75067-3437 |
Second Address | Lewisville, TX 75067-3437 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2006 |
Last Update Date | 23/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
190455902 | (05) | TX |
OA3500 | (02) | TX |