Provider Demographics
NPI:1780763938
Name:TABATABAIAN, JAVAD (MD)
Entity type:Individual
Prefix:DR
First Name:JAVAD
Middle Name:
Last Name:TABATABAIAN
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:PO BOX 41056
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45441
Mailing Address - Country:US
Mailing Address - Phone:937-277-5367
Mailing Address - Fax:937-277-6919
Practice Address - Street 1:2200 PHILADELPHIA DR
Practice Address - Street 2:SUITE 544
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1830
Practice Address - Country:US
Practice Address - Phone:937-277-5367
Practice Address - Fax:937-277-6919
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35035392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000020993OtherANTHEM
0403007OtherUHC
OH0836939Medicaid
OH0836939Medicaid
TA0693234Medicare ID - Type Unspecified