Provider Demographics
NPI:1861558918
Name:REZZADEH, RUDY ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:RUDY
Middle Name:ROBERT
Last Name:REZZADEH
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 1:1990 WESTWOOD BLVD
Mailing Address - Street 2:220
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4650
Mailing Address - Country:US
Mailing Address - Phone:424-832-7110
Mailing Address - Fax:424-832-7113
Practice Address - Street 1:1990 WESTWOOD BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4650
Practice Address - Country:US
Practice Address - Phone:424-832-7110
Practice Address - Fax:424-832-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184330-1174400000X
NJ25MA06442200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01249178Medicaid
NYF00934Medicare UPIN
NY00G891Medicare UPIN
NY00G891Medicare ID - Type UnspecifiedMEDICARE