Healthcare Provider Details

I. General information

NPI: 1205127404
Provider Name (Legal Business Name): MARYAM TABRIZI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W 14TH STREET
WILMINGTON DE
19801-1013
US

IV. Provider business mailing address

200 HYGEIA DRIVE SUITE 2300
NEWARK DE
19713-2049
US

V. Phone/Fax

Practice location:
  • Phone: 302-320-4410
  • Fax: 785-273-0524
Mailing address:
  • Phone: 785-273-7571
  • Fax: 785-273-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-37330
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC1-0012410
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: