Provider Demographics
NPI:1417231457
Name:SAFRI, TABASSUM (MD)
Entity Type:Individual
Prefix:
First Name:TABASSUM
Middle Name:
Last Name:SAFRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4386
Mailing Address - Country:US
Mailing Address - Phone:770-670-6923
Mailing Address - Fax:770-670-6927
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-670-6923
Practice Address - Fax:770-670-6927
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263146207R00000X
GA72110207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003159046AMedicaid
GA003159046AMedicaid