Provider Demographics
NPI:1376988535
Name:EHSANIAN, REZA
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:EHSANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91902
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC10 5615; UNM NEUROSURGERY; DIVISION OF PM&R
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131
Practice Address - Country:US
Practice Address - Phone:505-925-7569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA155700208D00000X
NMMD2021-0789208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice