Provider Demographics
NPI:1003070129
Name:AHMADIAN, HOMAYOUN REZA (DO)
Entity Type:Individual
Prefix:
First Name:HOMAYOUN
Middle Name:REZA
Last Name:AHMADIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 VOLTERRA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-1612
Mailing Address - Country:US
Mailing Address - Phone:901-605-0522
Mailing Address - Fax:
Practice Address - Street 1:8060 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1727
Practice Address - Country:US
Practice Address - Phone:901-271-1000
Practice Address - Fax:901-271-4187
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4002207RC0000X
IN02003643A207RC0000X
390200000X
TN3601207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program