Provider Demographics
NPI:1104005370
Name:ARDEHALI, REZA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:ARDEHALI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 CAMBRIDGE ST FL 6
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4202
Mailing Address - Country:US
Mailing Address - Phone:713-798-5525
Mailing Address - Fax:
Practice Address - Street 1:7200 CAMBRIDGE ST FL 6
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4202
Practice Address - Country:US
Practice Address - Phone:713-798-2545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91843207R00000X, 207RC0000X, 282N00000X
TXU2144207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104005370Medicaid
CA1104005370OtherCCS (MEDICAID)
CAFY851Medicare PIN