Basic Information
| Provider Information | |||||||||
| NPI: | 1598723538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REZA | ||||||||
| FirstName: | ALI | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4398 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953524398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754575 | ||||||||
| FaxNumber: | 2095754575 | ||||||||
| Practice Location | |||||||||
| Address1: | 2141 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953822011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096342600 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 09458R | LA | N | Other Service Providers | Specialist | 207RC0000X | A50089 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1973254 | 05 | LA | MEDICAID |