Provider Demographics
NPI:1205360484
Name:ALIZADEH, REZA (MD)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:ALIZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1807 WILSHIRE BLVD STE 203
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5790
Practice Address - Country:US
Practice Address - Phone:310-829-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178828207WX0009X
OH35.141784207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0441846Medicaid