Basic Information
| Provider Information | |||||||||
| NPI: | 1356337372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REZAEI | ||||||||
| FirstName: | LALEH | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 STATE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129452229 | ||||||||
| FaxNumber: | 8129492229 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 STATE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129452229 | ||||||||
| FaxNumber: | 8129492229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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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 | 208000000X | 01048835A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200193210A | 05 | IN | MEDICAID | 351708493 | 01 | IN | TAX ID# | OTHER |