Provider Demographics
NPI:1770516585
Name:REZVAN, MASOUD (MD)
Entity type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:
Last Name:REZVAN
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 1:3131 PRINCETON PIKE
Mailing Address - Street 2:BLD 5 SUITE 109
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2201
Mailing Address - Country:US
Mailing Address - Phone:609-912-1145
Mailing Address - Fax:609-912-1147
Practice Address - Street 1:3131 PRINCETON PIKE
Practice Address - Street 2:BLD 5 SUITE 109
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2201
Practice Address - Country:US
Practice Address - Phone:609-912-1145
Practice Address - Fax:609-912-1147
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ155620208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3031802Medicaid
NJ155620Medicare ID - Type Unspecified
NJC53624Medicare UPIN