Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | A113116 | CA |
Y | 111NI0900X | Internist | A113116 | CA |
N | 207U00000X | Nuclear Medicine Specialist | 4301086547 | MI |
N | 207U00000X | Nuclear Medicine Specialist | A113116 | CA |
NPI | 1487976668 |
---|---|
Provider Name | Mohammad Rezvani |
First Address | Los Angeles, CA 90049-5105 |
Second Address | Los Angeles, CA 90034-3712 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2010 |
Last Update Date | 28/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A113116 | LICENSE (01) | CA |
GR0066315 | (05) | CA |