Provider Demographics
NPI:1982637922
Name:MIREMADI, A REZA (MD, DDS, LLC)
Entity Type:Individual
Prefix:
First Name:A
Middle Name:REZA
Last Name:MIREMADI
Suffix:
Gender:M
Credentials:MD, DDS, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9552
Mailing Address - Country:US
Mailing Address - Phone:937-748-8814
Mailing Address - Fax:937-748-8817
Practice Address - Street 1:576 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9552
Practice Address - Country:US
Practice Address - Phone:937-748-8814
Practice Address - Fax:937-748-8817
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21379174400000X
OH79671204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2421132Medicaid
OH2421132Medicaid
OHMI4117311Medicare PIN