Provider Demographics
NPI:1013962539
Name:MOBARAK, REZA (DPM)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:MOBARAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:502 N VALLEY PKWY
Mailing Address - Street 2:STE 2
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3437
Mailing Address - Country:US
Mailing Address - Phone:972-316-0902
Mailing Address - Fax:972-316-1161
Practice Address - Street 1:502 N VALLEY PKWY
Practice Address - Street 2:STE 2
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3437
Practice Address - Country:US
Practice Address - Phone:972-316-0902
Practice Address - Fax:972-316-1161
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1714213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190455902Medicaid
TX6237770001Medicare NSC