Provider Demographics
NPI:1265468748
Name:MEHZAD, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:MEHZAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MACK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5335
Mailing Address - Country:US
Mailing Address - Phone:513-751-4222
Mailing Address - Fax:513-874-3023
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-751-4222
Practice Address - Fax:513-874-3023
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9368207R00000X
OH35-089772207R00000X, 207RC0001X
OH35089772207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2840493Medicaid
MN278600000Medicaid
MNI 18599Medicare UPIN
OH4228351Medicare PIN
OH2840493Medicaid