Provider Demographics
NPI:1053477703
Name:YAVARI, REZA (MD)
Entity type:Individual
Prefix:MR
First Name:REZA
Middle Name:
Last Name:YAVARI
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 1:1008 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3773
Mailing Address - Country:US
Mailing Address - Phone:203-315-2936
Mailing Address - Fax:203-315-2940
Practice Address - Street 1:1008 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3773
Practice Address - Country:US
Practice Address - Phone:203-315-2936
Practice Address - Fax:203-315-2940
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032568174400000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF49203Medicare UPIN