Provider Demographics
NPI:1013399195
Name:REZAI, MOHAMMED TAGHI (DO)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:TAGHI
Last Name:REZAI
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 1:455 E THOUSAND OAKS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5800
Mailing Address - Country:US
Mailing Address - Phone:818-232-5788
Mailing Address - Fax:
Practice Address - Street 1:455 E THOUSAND OAKS BLVD STE B
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5800
Practice Address - Country:US
Practice Address - Phone:818-232-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14895207QA0401X, 2083A0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty