Provider Demographics
NPI:1790363356
Name:REWANE, AYESAN
Entity type:Individual
Prefix:DR
First Name:AYESAN
Middle Name:
Last Name:REWANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6424 N RIDGE BLVD APT 1D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4831
Mailing Address - Country:US
Mailing Address - Phone:240-716-9552
Mailing Address - Fax:
Practice Address - Street 1:3201 SPRINGHILL DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2905
Practice Address - Country:US
Practice Address - Phone:501-955-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN70889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine