Basic Information
| Provider Information | |||||||||
| NPI: | 1285607606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERJIS | ||||||||
| FirstName: | REZA | ||||||||
| MiddleName: | ROY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10555 SE CARR RD | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256564270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11650 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD6069869 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1285607606 | 05 | NV | MEDICAID | 2073553 | 05 | WA | MEDICAID |