Provider Demographics
NPI:1679316277
Name:ETEMAD-REZAIE, ALI (MD, MS, FRCSC)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:ETEMAD-REZAIE
Suffix:
Gender:M
Credentials:MD, MS, FRCSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ATWELL RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1301
Mailing Address - Country:US
Mailing Address - Phone:607-282-2003
Mailing Address - Fax:
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-282-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2025-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334214-01207X00000X, 207XX0005X
MI4301510967207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery