Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | D0060715 | MD |
N | 111NI0900X | Internist | D0060715 | MD |
Y | 207RG0100X | Gastroenterologist | MD60663353 | WA |
NPI | 1043219819 |
---|---|
Provider Name | Seyed Abdol Reza Jalali |
First Address | Puyallup, WA 98373-1585 |
Second Address | Puyallup, WA 98373-1585 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2005 |
Last Update Date | 04/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1000032342 | (05) | DE |
2061190 | (05) | WA |
404228000 | (05) | MD |
I11025 | (02) |