Provider Demographics
NPI:1134516578
Name:SHOKOUH-AMIRI, SOPHIA TAYEBEH (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:TAYEBEH
Last Name:SHOKOUH-AMIRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:ABDEHOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8951
Mailing Address - Fax:318-212-6752
Practice Address - Street 1:1327 PIERRE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-212-8624
Practice Address - Fax:318-226-8545
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA311260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2387707Medicaid