Basic Information
| Provider Information | |||||||||
| NPI: | 1689200701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KADIVAR | ||||||||
| FirstName: | SOHRAB | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 ARLINGTON AVENUE | ||||||||
| Address2: | RUPPERT HEALTH CENTER, ROOM 0012 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833685 | ||||||||
| FaxNumber: | 4193836244 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 ARLINGTON AVENUE | ||||||||
| Address2: | RUPPERT HEALTH CENTER, ROOM 0012 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833685 | ||||||||
| FaxNumber: | 4193836244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.