Provider Demographics
NPI:1356350805
Name:FARSAD, G. REZA H (MD)
Entity type:Individual
Prefix:MR
First Name:G. REZA
Middle Name:H
Last Name:FARSAD
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 1:1401 N PALM CANYON DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4434
Mailing Address - Country:US
Mailing Address - Phone:760-320-3538
Mailing Address - Fax:760-320-4579
Practice Address - Street 1:1401 N PALM CANYON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4434
Practice Address - Country:US
Practice Address - Phone:760-320-3538
Practice Address - Fax:760-320-4579
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A378650174400000X
CAA037865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356350805-01Medicaid
CA1356350805Medicaid
CA1356350805Medicaid