Provider Demographics
NPI:1609134352
Name:KANANI, REZA (MD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:KANANI
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 1:10275 LITTLE PATUXENT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3445
Mailing Address - Country:US
Mailing Address - Phone:888-464-2466
Mailing Address - Fax:410-740-1518
Practice Address - Street 1:28651 RANCHO DEL SOL
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7416
Practice Address - Country:US
Practice Address - Phone:888-464-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1471232084N0400X
CA130512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400102504Medicare UPIN