Basic Information
| Provider Information | |||||||||
| NPI: | 1619402955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REZAEI MIRGHAED | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 Y ST STE 3700 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167346285 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3160 FOLSOM BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343588 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2017 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0008X | A171091 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neuromuscular Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | A171091 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1619402955 | 01 | TN | NPI | OTHER |