Provider Demographics
NPI:1457349359
Name:REZVANI, IRAJ (MD)
Entity Type:Individual
Prefix:
First Name:IRAJ
Middle Name:
Last Name:REZVANI
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:ERIE AVE AT FRONT ST
Mailing Address - Street 2:SCPA ENDOCRINOLOGY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-1095
Mailing Address - Country:US
Mailing Address - Phone:215-427-8822
Mailing Address - Fax:215-427-8830
Practice Address - Street 1:ERIE AVE AT FRONT ST
Practice Address - Street 2:SCPA ENDOCRINOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1095
Practice Address - Country:US
Practice Address - Phone:215-427-8822
Practice Address - Fax:215-427-8830
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033063L2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006658770004Medicaid
149548Medicare ID - Type Unspecified
PA0006658770004Medicaid