Provider Demographics
NPI:1861412827
Name:POURSHADI, REZA (DC)
Entity type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:POURSHADI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 RIVERSIDE AVENUE, SUITE C
Mailing Address - Street 2:RIVERSIDE CHIROPRACTIC CEN
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4653
Mailing Address - Country:US
Mailing Address - Phone:781-395-0003
Mailing Address - Fax:781-395-2223
Practice Address - Street 1:65 RIVERSIDE AVENUE, SUITE, C
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4653
Practice Address - Country:US
Practice Address - Phone:781-395-0003
Practice Address - Fax:781-395-2223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2413111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45476Medicare ID - Type Unspecified