Provider Demographics
NPI:1235364894
Name:BALAWI, TARIQ HESHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:HESHAM
Last Name:BALAWI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TARIQ
Other - Middle Name:HESHAM M
Other - Last Name:BALAWI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3417 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5064
Mailing Address - Country:US
Mailing Address - Phone:360-493-4600
Mailing Address - Fax:360-493-4603
Practice Address - Street 1:3417 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5064
Practice Address - Country:US
Practice Address - Phone:360-493-4600
Practice Address - Fax:360-493-4603
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1159922085R0202X
WAMD604643812085R0202X
IA410012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1235364894Medicaid
WAG8930160OtherMEDICARE PTAN