Provider Demographics
NPI:1275503393
Name:M. REZA MIZANI, M.D., P.A.
Entity type:Organization
Organization Name:M. REZA MIZANI, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-212-8622
Mailing Address - Street 1:PO BOX 650002
Mailing Address - Street 2:DEPT 8286
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265
Mailing Address - Country:US
Mailing Address - Phone:210-212-8622
Mailing Address - Fax:210-212-9197
Practice Address - Street 1:215 N SAN SABA STE 301
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3164
Practice Address - Country:US
Practice Address - Phone:210-212-8622
Practice Address - Fax:210-212-9197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2086S0129X, 207RN0300X
TX1596213E00000X
TXL2477207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167911002Medicaid
TX00158XMedicare PIN