Healthcare Provider Details

I. General information

NPI: 1407607773
Provider Name (Legal Business Name): TARIQ ALI ISLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12607 SE MILL PLAIN BLVD
VANCOUVER WA
98684-6055
US

IV. Provider business mailing address

500 NE MULTNOMAH ST STE 100
PORTLAND OR
97232-2099
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone: 800-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.MD.70115935
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: