Provider Demographics
NPI:1255346797
Name:GOVASHIRI, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:GOVASHIRI
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 1:24421 CALLE DE LA LOUISA STE 200
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7609
Mailing Address - Country:US
Mailing Address - Phone:949-830-4201
Mailing Address - Fax:949-830-4223
Practice Address - Street 1:24421 CALLE DE LA LOUISA STE 200
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7609
Practice Address - Country:US
Practice Address - Phone:949-830-4201
Practice Address - Fax:949-830-4223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF51487Medicare UPIN
CAA50068AMedicare ID - Type Unspecified