Provider Demographics
NPI:1548290562
Name:MOZAYENI, REZA MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:MICHAEL
Last Name:MOZAYENI
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 1:3025 SPRINGBANK LANE
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3362
Mailing Address - Country:US
Mailing Address - Phone:704-540-9595
Mailing Address - Fax:704-540-9616
Practice Address - Street 1:3025 SPRINGBANK LANE
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3362
Practice Address - Country:US
Practice Address - Phone:704-540-9595
Practice Address - Fax:704-540-9616
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-00102207W00000X
NC200000102207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G27803Medicare UPIN
2000941Medicare PIN
NCG27803Medicare UPIN