Provider Demographics
NPI:1720026792
Name:REZAEI, KIANOUSH V (MD)
Entity Type:Individual
Prefix:
First Name:KIANOUSH
Middle Name:V
Last Name:REZAEI
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 1:1675 E MAIN ST
Mailing Address - Street 2:BOX 328
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-5818
Mailing Address - Country:US
Mailing Address - Phone:330-593-1048
Mailing Address - Fax:330-572-3836
Practice Address - Street 1:1675 E MAIN ST
Practice Address - Street 2:BOX 328
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-5818
Practice Address - Country:US
Practice Address - Phone:330-593-1048
Practice Address - Fax:330-572-3836
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1019182085R0202X
OH35.1256692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121669Medicaid
OH0121669Medicaid