Healthcare Provider Details

I. General information

NPI: 1437833779
Provider Name (Legal Business Name): TBI VIRTUAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 CONVOY ST STE 301
SAN DIEGO CA
92111-3741
US

IV. Provider business mailing address

3750 CONVOY ST STE 301
SAN DIEGO CA
92111-3741
US

V. Phone/Fax

Practice location:
  • Phone: 866-551-0080
  • Fax:
Mailing address:
  • Phone: 866-551-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: HAMID DJALILIAN
Title or Position: CHIEF MEDICAL ADVISOR
Credential: MD
Phone: 866-551-0080