Provider Demographics
NPI:1467537480
Name:EHSAN, REZA RAY (MD)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:RAY
Last Name:EHSAN
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 1:11600 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4014
Mailing Address - Country:US
Mailing Address - Phone:310-390-9551
Mailing Address - Fax:310-390-9296
Practice Address - Street 1:11600 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4014
Practice Address - Country:US
Practice Address - Phone:310-390-9551
Practice Address - Fax:310-390-9296
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50372207L00000X, 207LP2900X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467537480Medicaid
CA1467537480Medicare NSC