Provider Demographics
NPI:1902066236
Name:REZAEE, ZIBA (MD)
Entity Type:Individual
Prefix:
First Name:ZIBA
Middle Name:
Last Name:REZAEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 RANCH ROAD 620 S
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6311
Mailing Address - Country:US
Mailing Address - Phone:512-263-5100
Mailing Address - Fax:512-263-5104
Practice Address - Street 1:1205 RANCH ROAD 620 S
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6311
Practice Address - Country:US
Practice Address - Phone:512-263-5100
Practice Address - Fax:512-263-5104
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-00320792084P0800X
TXN78642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2939571Medicaid