Provider Demographics
NPI:1982635363
Name:EMAMI, REZA (MD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:EMAMI
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 1:600 ROE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1629
Mailing Address - Country:US
Mailing Address - Phone:607-737-4100
Mailing Address - Fax:
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-737-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA077344207P00000X
NY194489207PE0004X, 207P00000X
PAMD426464207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA077344OtherMEDICAL LICENSE
NJ0049778Medicaid
PA101960050 0006Medicaid
PA101960050 0006Medicaid
NJMA077344OtherMEDICAL LICENSE
NJ0049778Medicaid