Provider Demographics
NPI:1679726905
Name:TABATABAII, ASHRAF (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHRAF
Middle Name:
Last Name:TABATABAII
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHRAFOSSADT
Other - Middle Name:
Other - Last Name:TABATABAII
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:421 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3160
Mailing Address - Country:US
Mailing Address - Phone:601-798-0511
Mailing Address - Fax:
Practice Address - Street 1:421 RIVER RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3160
Practice Address - Country:US
Practice Address - Phone:601-798-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10074208000000X
LA016970208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1354180Medicaid
MS0019568Medicaid
MS25D0319246OtherCLIA