Provider Demographics
NPI:1033130679
Name:REZAEI, ROSS (OTR/L, HTC)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:
Last Name:REZAEI
Suffix:
Gender:M
Credentials:OTR/L, HTC
Other - Prefix:MR
Other - First Name:RASOUL
Other - Middle Name:
Other - Last Name:ASGHAR-REZAEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L, HTC
Mailing Address - Street 1:22 ODYSSEY STE 165
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3194
Mailing Address - Country:US
Mailing Address - Phone:949-727-2192
Mailing Address - Fax:949-727-2193
Practice Address - Street 1:22 ODYSSEY
Practice Address - Street 2:SUITE 165
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3186
Practice Address - Country:US
Practice Address - Phone:949-727-2192
Practice Address - Fax:949-727-2193
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT1251225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3791439Medicaid
CAOT0012510OtherBLUE SHIELD OF CALIFORNIA
CAOT0012510OtherBLUE SHIELD OF CALIFORNIA