Provider Demographics
NPI:1770701542
Name:REZVANI, MARYAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:REZVANI
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 1:30 N 1900 E
Mailing Address - Street 2:#1A71
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-2140
Mailing Address - Country:US
Mailing Address - Phone:801-581-7553
Mailing Address - Fax:
Practice Address - Street 1:30 NORTH 1900 EAST
Practice Address - Street 2:#1A71
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-8699
Practice Address - Fax:801-581-2414
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT658681312052085B0100X
IL036-1154122085B0100X
IN01060592A2085B0100X
UT6586813-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging