Provider Demographics
NPI:1003339722
Name:BENRAZAVI, SOHEILA (MD)
Entity Type:Individual
Prefix:
First Name:SOHEILA
Middle Name:
Last Name:BENRAZAVI
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 1:4730 HOEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7868
Mailing Address - Country:US
Mailing Address - Phone:707-528-1616
Mailing Address - Fax:
Practice Address - Street 1:4730 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9540
Practice Address - Country:US
Practice Address - Phone:707-528-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000000000OtherNO OTHER PROVIDER ID
00000000000OtherNO OTHER PROVIDER NUMBER ARE AVAILABLE