Provider Demographics
NPI:1740700111
Name:M. REZA MIZANI, M.D., P.A.
Entity type:Organization
Organization Name:M. REZA MIZANI, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:MIZANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-212-8622
Mailing Address - Street 1:PO BOX 504152
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4152
Mailing Address - Country:US
Mailing Address - Phone:210-212-8622
Mailing Address - Fax:210-212-9197
Practice Address - Street 1:215 N SAN SABA STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3120
Practice Address - Country:US
Practice Address - Phone:210-547-3430
Practice Address - Fax:210-229-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130337261QA1903X
TXM8559207RN0300X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty