Provider Demographics
NPI:1699827402
Name:BORHANI, REZA SAM (DO)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:SAM
Last Name:BORHANI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MERCED ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4201
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 MERCED ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8433207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX84330Medicaid
CA00AX84330Medicaid
020A84330Medicare ID - Type Unspecified