Provider Demographics
NPI:1295155109
Name:REZAEIAN, PANTEHA (MD)
Entity type:Individual
Prefix:DR
First Name:PANTEHA
Middle Name:
Last Name:REZAEIAN
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 1:11234 ANDERSON ST
Mailing Address - Street 2:GME OFFICE WESTERLY SUITE C
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:909-558-6688
Mailing Address - Fax:
Practice Address - Street 1:127 S. VICENTE AHSP 3106
Practice Address - Street 2:127 S. VICENTE BLVD, AHSP A3200-06
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:424-247-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ84828390200000X
CAA143802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program