Basic Information
| Provider Information | |||||||||
| NPI: | 1043219819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JALALI | ||||||||
| FirstName: | SEYED ABDOL | ||||||||
| MiddleName: | REZA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 S MERIDIAN STE 350 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983731585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534455750 | ||||||||
| FaxNumber: | 2534264142 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 S MERIDIAN STE 350 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983731585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534455750 | ||||||||
| FaxNumber: | 2534264142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0060715 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | MD60663353 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1000032342 | 05 | DE | MEDICAID | 2061190 | 05 | WA | MEDICAID | 404228000 | 05 | MD | MEDICAID |