Provider Demographics
NPI:1336437904
Name:REZA NABAVIAN, MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:REZA NABAVIAN, MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-829-5550
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:1180W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-5550
Mailing Address - Fax:310-829-5502
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:1180W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-829-5550
Practice Address - Fax:310-829-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA062706208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA62706Medicare UPIN