Provider Demographics
NPI:1285732289
Name:LARY, MAHNAZ (MD)
Entity type:Individual
Prefix:
First Name:MAHNAZ
Middle Name:
Last Name:LARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2524
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-2524
Mailing Address - Country:US
Mailing Address - Phone:360-671-7100
Mailing Address - Fax:360-671-3538
Practice Address - Street 1:1211 CORNWALL AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5020
Practice Address - Country:US
Practice Address - Phone:360-671-7100
Practice Address - Fax:360-671-3538
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8912983Medicare PIN
IL277000OtherHEALTHLINK
IL039386OtherHEALTH ALLIANCE
IL0360918252Medicaid
ILL83861Medicare ID - Type Unspecified