Provider Demographics
NPI:1952530578
Name:REZA MOJTABAVI, M.D. PLLC
Entity Type:Organization
Organization Name:REZA MOJTABAVI, M.D. PLLC
Other - Org Name:AVENCIA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOJTABAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-445-7770
Mailing Address - Street 1:PO BOX 34707
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-4707
Mailing Address - Country:US
Mailing Address - Phone:702-445-7770
Mailing Address - Fax:702-445-7772
Practice Address - Street 1:3150 N TENAYA WAY
Practice Address - Street 2:SUITE 240
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0443
Practice Address - Country:US
Practice Address - Phone:702-445-7770
Practice Address - Fax:702-445-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1952530578Medicaid
CF646A GROUPMedicare PIN
NV13155OtherMEDICAL LICENSES