Provider Demographics
NPI:1508022781
Name:REZVAN, AZADEH (MD)
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:REZVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 SE SUNNYSIDE RD. MT TALBERT MEDICAL OFFICE,
Mailing Address - Street 2:DEPARTMENT OF OB/GYN, DIVISION OF UROGYNECOLOGY
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015
Mailing Address - Country:US
Mailing Address - Phone:503-652-2880
Mailing Address - Fax:
Practice Address - Street 1:10100 SE SUNNYSIDE RD
Practice Address - Street 2:MT TALERT MEDICAL OFFICE, DIVISION OF UROGYNECOLOGY
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171989207VF0040X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program