Healthcare Provider Details

I. General information

NPI: 1205584588
Provider Name (Legal Business Name): JEAN ELIE TABBAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 MEDICAL PARK DR
DURHAM NC
27704-2388
US

IV. Provider business mailing address

417 BUCK JONES RD
RALEIGH NC
27606-1203
US

V. Phone/Fax

Practice location:
  • Phone: 919-668-7600
  • Fax:
Mailing address:
  • Phone: 984-212-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2022-00474
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: