Provider Demographics
NPI:1356337372
Name:REZAEI, LALEH (MD)
Entity type:Individual
Prefix:
First Name:LALEH
Middle Name:
Last Name:REZAEI
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 1:1425 STATE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4909
Mailing Address - Country:US
Mailing Address - Phone:812-945-2229
Mailing Address - Fax:812-949-2229
Practice Address - Street 1:1425 STATE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4909
Practice Address - Country:US
Practice Address - Phone:812-945-2229
Practice Address - Fax:812-949-2229
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048835A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200193210AMedicaid
IN351708493OtherTAX ID#