Provider Demographics
NPI:1043219819
Name:JALALI, SEYED ABDOL REZA (MD)
Entity type:Individual
Prefix:
First Name:SEYED ABDOL
Middle Name:REZA
Last Name:JALALI
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 1:2910 S MERIDIAN STE 350
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1585
Mailing Address - Country:US
Mailing Address - Phone:253-445-5750
Mailing Address - Fax:253-426-4142
Practice Address - Street 1:2910 S MERIDIAN STE 350
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1585
Practice Address - Country:US
Practice Address - Phone:253-445-5750
Practice Address - Fax:253-426-4142
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060715207R00000X
WAMD60663353207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000032342Medicaid
WA2061190Medicaid
MD404228000Medicaid
DE1000032342Medicaid