Provider Demographics
NPI:1760844708
Name:VAZIRI, KAMYAR (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMYAR
Middle Name:
Last Name:VAZIRI
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 1:9230 SKY ISLAND DR E STE 101
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7385
Mailing Address - Country:US
Mailing Address - Phone:253-750-6110
Mailing Address - Fax:253-922-5299
Practice Address - Street 1:9230 SKY ISLAND DR E FL 2
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7385
Practice Address - Country:US
Practice Address - Phone:253-750-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60886183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2076944Medicaid