Basic Information
| Provider Information | |||||||||
| NPI: | 1205127404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABRIZI | ||||||||
| FirstName: | MARYAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DRIVE | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852737571 | ||||||||
| FaxNumber: | 7852730524 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 W 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198011013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023204410 | ||||||||
| FaxNumber: | 7852730524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 12/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 04-37330 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C1-0012410 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | KA2129030 | 01 | KS | MEDICARE PTAN | OTHER |