Basic Information
Provider Information
NPI: 1003140922
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: REZVAN
FirstName: KAVEH
MiddleName: N
NamePrefix: DR.
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2815 S MAIN ST STE 100
Address2:  
City: CORONA
State: CA
PostalCode: 928822532
CountryCode: US
TelephoneNumber: 9513716600
FaxNumber:  
Practice Location
Address1: 2815 S MAIN ST STE 100
Address2:  
City: CORONA
State: CA
PostalCode: 928822532
CountryCode: US
TelephoneNumber: 9513716600
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/24/2009
LastUpdateDate: 08/20/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X20A10932CAN Allopathic & Osteopathic PhysiciansInternal Medicine 
207RP1001X20A10932CAY Allopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease

No ID Information.


Home