Provider Demographics
NPI:1891894838
Name:MAHRAM, REZA
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:MAHRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:3114 CROASDAILE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2508
Practice Address - Country:US
Practice Address - Phone:919-425-1565
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054315207P00000X
FLME103889207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA016386631CMedicaid
GA016386631CMedicaid