Provider Demographics
NPI:1326016296
Name:TAVAKOLI, SIRPA A (MD)
Entity Type:Individual
Prefix:DR
First Name:SIRPA
Middle Name:A
Last Name:TAVAKOLI
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 1:1743 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0927
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:
Practice Address - Street 1:1743 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0927
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD250612084P0800X
CAA873732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213320Medicaid
132574Medicare ID - Type Unspecified
CAW416Medicare PIN
H63587Medicare UPIN