Provider Demographics
NPI:1336175272
Name:SHIRAZI, REZA (MD)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:SHIRAZI
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:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:858-888-7721
Practice Address - Street 1:3366 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5713
Practice Address - Country:US
Practice Address - Phone:619-230-0400
Practice Address - Fax:858-429-7936
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95800174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11621447OtherCAQH ID
CA00A958000Medicaid
CAA95800OtherSTATE LICENSE
OH87929OtherOHIO STATE LICENSE
CAWA95800BMedicare PIN
CA11621447OtherCAQH ID
OH87929OtherOHIO STATE LICENSE
CAA95800OtherSTATE LICENSE
CAWA95800GMedicare UPIN
CA00A958000Medicaid
CAWA95800DMedicare PIN
CAWA95800FMedicare PIN