Provider Demographics
NPI:1497813331
Name:M. REZA MIZANI, M.D., P.A.
Entity Type:Organization
Organization Name:M. REZA MIZANI, M.D., P.A.
Other - Org Name:SOUTH TEXAS RENAL CARE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:MIZANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-212-8622
Mailing Address - Street 1:PO BOX 504152
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4152
Mailing Address - Country:US
Mailing Address - Phone:210-212-8622
Mailing Address - Fax:210-212-9197
Practice Address - Street 1:215 N SAN SABA STE 301
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-8101
Practice Address - Country:US
Practice Address - Phone:210-212-8622
Practice Address - Fax:210-212-9197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191158801Medicaid
TX0017PXOtherBCBS
TXP00440046OtherMEDICARE RAILROAD
TX0017PXOtherBCBS
TXP00440046OtherMEDICARE RAILROAD
TX205978580OtherEIN
TXG42073Medicare UPIN
TX0017PXOtherBCBS