Provider Demographics
NPI:1275503393
Name:M. REZA MIZANI, M.D., P.A.
Entity Type:Organization
Organization Name:M. REZA MIZANI, M.D., P.A.
Other - Org Name:SOU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAMARILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-212-8622
Mailing Address - Street 1:PO BOX 504152
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4152
Mailing Address - Country:US
Mailing Address - Phone:210-212-8622
Mailing Address - Fax:210-212-9197
Practice Address - Street 1:215 N SAN SABA STE 301
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3164
Practice Address - Country:US
Practice Address - Phone:210-212-8622
Practice Address - Fax:210-212-9197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7871207RC0000X
TXL2477207RN0300X
TXG7417208600000X
TX1596213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167911002Medicaid
TX00158XMedicare PIN