Provider Demographics
NPI:1790326791
Name:TIZABI, REUEL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:REUEL
Middle Name:
Last Name:TIZABI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13212 SERPENTINE WAY
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-5345
Mailing Address - Country:US
Mailing Address - Phone:240-994-4596
Mailing Address - Fax:
Practice Address - Street 1:16630 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-2716
Practice Address - Country:US
Practice Address - Phone:310-768-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist