Provider Demographics
NPI:1487995304
Name:SODDY DAISY FAMILY CARE
Entity type:Organization
Organization Name:SODDY DAISY FAMILY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KAUKAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-451-0623
Mailing Address - Street 1:9089 DAYTON PIKE
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379
Mailing Address - Country:US
Mailing Address - Phone:423-451-0622
Mailing Address - Fax:423-451-0624
Practice Address - Street 1:9089 DAYTON PIKE
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4313
Practice Address - Country:US
Practice Address - Phone:423-451-0622
Practice Address - Fax:423-451-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29446207R00000X
TN28243208000000X
TN37633208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509389Medicaid
TN3887638Medicaid
TN1511723Medicaid
TN102119I153Medicare PIN