Basic Information
| Provider Information | |||||||||
| NPI: | 1487849378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAHERI | ||||||||
| FirstName: | SOHA | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 91-2141 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967061993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086913000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 91-2141 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967061993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086913000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 062008 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 62008 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | MD-21941 | HI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | G62008 | 05 | SC | MEDICAID | 582162071-040 | 01 | HMHS/TRICARE SOUTH | OTHER | 52305514-001 | 01 | GA | BCBS | OTHER | P00687389 | 01 | GA | RR MEDICARE | OTHER | 799561945A | 05 | GA | MEDICAID |