Basic Information
| Provider Information | |||||||||
| NPI: | 1043421811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REZVANIAN | ||||||||
| FirstName: | SHIVA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6801 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEWATER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088070801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9083876611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 185 ROSEBERRY ST | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088651690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088351910 | ||||||||
| FaxNumber: | 9088351886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N-A | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 218847 | 05 | NJ | MEDICAID |