Provider Demographics
NPI:1447223417
Name:DEMIRJIAN, KEITH E (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:DEMIRJIAN
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 1:1812 S J ST
Mailing Address - Street 2:#102
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4964
Mailing Address - Country:US
Mailing Address - Phone:253-552-4900
Mailing Address - Fax:253-627-1886
Practice Address - Street 1:1812 S J ST
Practice Address - Street 2:#102
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4964
Practice Address - Country:US
Practice Address - Phone:253-552-4900
Practice Address - Fax:253-627-1886
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1770304Medicaid
WAA08546Medicare UPIN
WA1770304Medicaid