Provider Demographics
NPI:1275517153
Name:GAMAGAMI, REZA ALEX (MD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:ALEX
Last Name:GAMAGAMI
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9524
Mailing Address - Country:US
Mailing Address - Phone:815-717-8730
Mailing Address - Fax:815-717-8729
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9524
Practice Address - Country:US
Practice Address - Phone:815-717-8730
Practice Address - Fax:815-717-8729
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-03
Last Update Date:2024-01-18
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Provider Licenses
StateLicense IDTaxonomies
IL036-103521208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-103521Medicaid
IL036-103521Medicaid