Provider Demographics
NPI:1649376229
Name:DANESH, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:DANESH
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 1:10931 CHERRY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2496
Mailing Address - Country:US
Mailing Address - Phone:562-497-9229
Mailing Address - Fax:562-431-0108
Practice Address - Street 1:10931 CHERRY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2496
Practice Address - Country:US
Practice Address - Phone:562-497-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055334208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A55334Medicaid
CA00A55334Medicaid
55334Medicare ID - Type Unspecified