Provider Demographics
NPI:1801983317
Name:ROD, REZA A (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:A
Last Name:ROD
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 1:2525 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4948
Mailing Address - Country:US
Mailing Address - Phone:602-344-8435
Mailing Address - Fax:
Practice Address - Street 1:2525 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4948
Practice Address - Country:US
Practice Address - Phone:602-344-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN490222086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472458000Medicaid
I61176Medicare UPIN
MN240000319Medicare ID - Type Unspecified