Provider Demographics
NPI:1821294000
Name:REZAIE, ANAHITA (MD)
Entity Type:Individual
Prefix:
First Name:ANAHITA
Middle Name:
Last Name:REZAIE
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 1:1417 S WESTGATE AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:626-256-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047553207RG0100X
CAC55510207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8489965Medicaid
WAMD00047553OtherWA LICENSE
WA8867589Medicare PIN
WAG8851596Medicare PIN
WAP00430009Medicare PIN
WA001045700Medicare PIN
WA000188100Medicare PIN
WAG8851595Medicare PIN
WA8867590Medicare PIN
WAG8880511Medicare PIN
WAG8851594Medicare PIN
WAG8851597Medicare PIN
WA8851594Medicare PIN