Provider Demographics
NPI:1902879687
Name:GHOHESTANI, REZA FREDRICK (MD PHD)
Entity Type:Individual
Prefix:PROF
First Name:REZA
Middle Name:FREDRICK
Last Name:GHOHESTANI
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24165 W INTERSTATE 10
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1114
Mailing Address - Country:US
Mailing Address - Phone:210-846-5350
Mailing Address - Fax:844-819-1872
Practice Address - Street 1:24165 WEST IH-10
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257
Practice Address - Country:US
Practice Address - Phone:210-846-5350
Practice Address - Fax:210-547-7913
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427324207N00000X
TXN0043207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology