Provider Demographics
NPI:1205127404
Name:TABRIZI, MARYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:TABRIZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DRIVE
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:785-273-7571
Mailing Address - Fax:785-273-0524
Practice Address - Street 1:501 W 14TH STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1013
Practice Address - Country:US
Practice Address - Phone:302-320-4410
Practice Address - Fax:785-273-0524
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-37330208000000X
DEC1-0012410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2129030OtherMEDICARE PTAN