Provider Demographics
NPI:1811950942
Name:REZAEI, ABOLGHASEM MARCO (MD)
Entity type:Individual
Prefix:
First Name:ABOLGHASEM
Middle Name:MARCO
Last Name:REZAEI
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 1:4121 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6336
Mailing Address - Country:US
Mailing Address - Phone:580-699-5511
Mailing Address - Fax:580-699-5519
Practice Address - Street 1:4121 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6336
Practice Address - Country:US
Practice Address - Phone:580-699-5511
Practice Address - Fax:580-699-5519
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200097020BMedicaid
OKI52055OtherUPIN
OK1811950942OtherNPI