Provider Demographics
NPI:1053450627
Name:TABIBI, REZA (MD)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:TABIBI
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 34036
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1036
Mailing Address - Country:US
Mailing Address - Phone:425-899-3292
Mailing Address - Fax:425-899-3269
Practice Address - Street 1:11521 NE 128TH ST STE 100
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4317
Practice Address - Country:US
Practice Address - Phone:425-899-6800
Practice Address - Fax:425-899-6808
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047541207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8944545OtherCRIME VICTIMS
WA8480790Medicaid
WA0220450OtherLABOR & IND.
OR243067Medicaid
P00410143OtherRAILROAD MEDICARE
WA8480790Medicaid
OR243067Medicaid