Provider Demographics
NPI:1376650465
Name:REZVANI, FIROOZ (MD)
Entity Type:Individual
Prefix:
First Name:FIROOZ
Middle Name:
Last Name:REZVANI
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 1:640 BELLE TERRE RD
Mailing Address - Street 2:BLDG J
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-928-2121
Mailing Address - Fax:631-928-2127
Practice Address - Street 1:640 BELLE TERRE RD
Practice Address - Street 2:BLDG J
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-928-2121
Practice Address - Fax:631-928-2127
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128733207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00646295Medicaid
NY00646295Medicaid
B13476Medicare UPIN