Basic Information
| Provider Information | |||||||||
| NPI: | 1053450627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABIBI | ||||||||
| FirstName: | REZA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34036 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258993292 | ||||||||
| FaxNumber: | 4258993269 | ||||||||
| Practice Location | |||||||||
| Address1: | 11521 NE 128TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980344317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258996800 | ||||||||
| FaxNumber: | 4258996808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00047541 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | MD00047541 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8944545 | 01 | WA | CRIME VICTIMS | OTHER | 8480790 | 05 | WA | MEDICAID | 0220450 | 01 | WA | LABOR & IND. | OTHER | 243067 | 05 | OR | MEDICAID | P00410143 | 01 | RAILROAD MEDICARE | OTHER |