1740700111 NPI number — M. REZA MIZANI, M.D., P.A.

Table of content: (NPI 1740700111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740700111 NPI number — M. REZA MIZANI, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M. REZA MIZANI, M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TOTAL VASCULAR CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740700111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 504152
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-4152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-212-8622
Provider Business Mailing Address Fax Number:
210-212-9197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N SAN SABA STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78207-3120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-547-3430
Provider Business Practice Location Address Fax Number:
210-229-0606
Provider Enumeration Date:
06/26/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MIZANI
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
REZA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-212-8622

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  130337 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)