Provider Demographics
NPI:1871548404
Name:REZAI, KOUROSH (MD)
Entity type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:REZAI
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:6606 LYNDON B JOHNSON FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-233-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1978207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W1049OtherBCBS
TX153527002Medicaid
TX153527005OtherMEDICAID CSHCN
TX153527004Medicaid
TXP00387569OtherRAILROAD
TX153527003Medicaid
TXTXB148503Medicare PIN
TX153527005OtherMEDICAID CSHCN
TX8W1049OtherBCBS
TX153527002Medicaid