Provider Demographics
NPI:1053395731
Name:RASOULI, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:RASOULI
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 1:1665 SCENIC AVE
Mailing Address - Street 2:STE # 100
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1445
Mailing Address - Country:US
Mailing Address - Phone:714-436-4444
Mailing Address - Fax:
Practice Address - Street 1:1665 SCENIC AVE
Practice Address - Street 2:STE # 100
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1445
Practice Address - Country:US
Practice Address - Phone:714-436-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40509207RI0200X
CAA85426208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA42346Medicaid
LA4E443Medicare ID - Type Unspecified
LA42346Medicaid