Provider Demographics
NPI:1417044132
Name:RAEESY-NEZHAD, AMIR HOMAYON (MD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:HOMAYON
Last Name:RAEESY-NEZHAD
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 1:16311 VENTURA BLVD STE 955
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4339
Mailing Address - Country:US
Mailing Address - Phone:818-701-0017
Mailing Address - Fax:818-817-5541
Practice Address - Street 1:16311 VENTURA BLVD STE 955
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4339
Practice Address - Country:US
Practice Address - Phone:818-701-0017
Practice Address - Fax:818-817-5541
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36003207R00000X
CAA97308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA97308OtherMEDICAL LICENSE