Provider Demographics
NPI:1447423587
Name:TABIBIAZAR, RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:TABIBIAZAR
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 1:2030 FOREST AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4833
Mailing Address - Country:US
Mailing Address - Phone:415-671-5674
Mailing Address - Fax:
Practice Address - Street 1:2030 FOREST AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4833
Practice Address - Country:US
Practice Address - Phone:415-671-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69479207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH31624Medicare UPIN