Basic Information
Provider Information | |||||||||
NPI: | 1134516578 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHOKOUH-AMIRI | ||||||||
FirstName: | SOPHIA | ||||||||
MiddleName: | TAYEBEH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ABDEHOU | ||||||||
OtherFirstName: | SOPHIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1202 LOUISIANA AVE | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711013910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182128951 | ||||||||
FaxNumber: | 3182126752 | ||||||||
Practice Location | |||||||||
Address1: | 1327 PIERRE AVE | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 71103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182128624 | ||||||||
FaxNumber: | 3182268545 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2015 | ||||||||
LastUpdateDate: | 02/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 311260 | LA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2387707 | 05 | LA |   | MEDICAID |