Provider Demographics
NPI:1487849378
Name:TAHERI, SOHA P (MD)
Entity Type:Individual
Prefix:
First Name:SOHA
Middle Name:P
Last Name:TAHERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-2141 FORT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1993
Mailing Address - Country:US
Mailing Address - Phone:808-691-3000
Mailing Address - Fax:
Practice Address - Street 1:91-2141 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1993
Practice Address - Country:US
Practice Address - Phone:808-691-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062008207R00000X
GA62008208M00000X
HIMD-21941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG62008Medicaid
582162071-040OtherHMHS/TRICARE SOUTH
GA52305514-001OtherBCBS
GAP00687389OtherRR MEDICARE
GA799561945AMedicaid
GA52305514-001OtherBCBS