Provider Demographics
NPI:1629877840
Name:TABAIE, ETHAN ALI
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ALI
Last Name:TABAIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 W TARON DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8145
Mailing Address - Country:US
Mailing Address - Phone:916-686-7300
Mailing Address - Fax:
Practice Address - Street 1:420 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4494
Practice Address - Country:US
Practice Address - Phone:312-503-8194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3980256207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery