Provider Demographics
NPI:1538429261
Name:REZAEI-BAZAZIZAD, KNEMA PASCAL (MD)
Entity type:Individual
Prefix:DR
First Name:KNEMA
Middle Name:PASCAL
Last Name:REZAEI-BAZAZIZAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KNEMA
Other - Middle Name:PASCAL
Other - Last Name:REZAEI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 215-CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:512-231-5516
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1807 W SLAUGHTER LN
Practice Address - Street 2:SUITE 490
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6230
Practice Address - Country:US
Practice Address - Phone:512-282-8967
Practice Address - Fax:512-406-7351
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10043774208000000X
TXQ3950208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX351475401Medicaid
TX351475402Medicaid
TX439041YKXVMedicare PIN
TX439041YKXYMedicare PIN