Basic Information
| Provider Information | |||||||||
| NPI: | 1043655186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEIKH | ||||||||
| FirstName: | JAZAB | ||||||||
| MiddleName: | ALI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALI | ||||||||
| OtherFirstName: | JAZAB | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 660 S COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1550 S PIONEER WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988374614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939780 | ||||||||
| FaxNumber: | 5097643260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2013 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R4778 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D81068 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60942724 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2018012912 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101259712 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2127955 | 05 | WA | MEDICAID |